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ESSENTIALS  OF  PHYSICAL  DIAGNOSIS 
OF  THE  CHEST  AND  ABDOMEN. 


THE  ESSENTIALS  OF 

PHYSICAL  DIAGNOSIS  OF  THE 

CHEST  AND  ABDOMEN 


BY 


J.  WALLACE  ANDERSON,  ^LD. 

PHYSICIAN   TO   THE   ROYAL    IXFIRMARY",    GLASGOW,    AXD    LECTrRER 

CM   MEDICIXE,    ROYAL    INFIRMARY"    MEDICAL   SCHOOL, 

AUTHOR   OF    "  MEDICAL   XlRSINf;  " 


MACMILLAN   &   CO 

1889 


PREFACE. 

Last  summer,  when  1  bad  occasion  to  take 
my  Ward  Tutorial  Class  under  my  own  care, 
I  had  a  difficulty  in  referring  the  Junior 
Students  to  a  simple  concise  work  on  Physical 
Diagnosis,  that  would  take  the  place,  to  some 
extent,  of  the  Clinical  Lecture,  and  leave  me 
more  time  for  Practical  Demonstration.  I  was 
induced  for  this  reason  to  write  the  present 
text-book,  in  the  hope  that  those  beginning 
the  study  of  Medicine  might  find  it  of  some 
service. 

The  paragraphs  in  smaller  type  may  be  read 
at  a  later^  stage,  as  they  deal  chieHy  with  what 
is  matter  of  opinion. 

ULASf40w,  March,  1S89. 


CONTENTS. 


PACE 


Intkoductory  :  General  Principles,         ...  l 

The  Physical  Ex.a.minatiox  of  the  Ltnus,        -  4 

Inspection  :  Form  of  the  Chest— Bilateral  De- 
formities —  Unilateral  Deformities  —  M  ove- 
ments  of  Respiration,     -----  6 

jNIensuration,       -         -         -         -         -         -         -         10 

Palpation  :  Vocal  Fremitus  —  Pleural  Fremitus — 

Bronchial  Fremitus, 20 

Percussion  :  Method  of  Percussion — Percussion 
Sounds — Percussion  of  Lungs  in  Health — 
Percussion  of  Lungs  in  Disease,     -         -         -         "Jl 

Auscultation  :  The  Stethoscope— Auscultation  in 
Health — Eespiration  Sounds — Auscultation 
in  Disease — Altered  Eespiration  Sounds — 
Rales — Vocal  Resonance,        -         -         -         -         45 

Succussion, 78 

The  Physical  Examination  of  the  Heart,  -  SO 

Xormal  Relation  of  Heart  to  Chest  Wall,  -  -  SO 

Inspection  :  In  Health — In  Disease,    -         -  -  83 

Palpation  :  In  Health — In  Disease,     -         -  .  86 

Percussion  :  In  Health — In  Disease,  -         -  -  89 

-Vuscultation  :  In  Health — Cardiac  Sounds — In 
Diseai=e—Eeduplication— Cardiac  Murmurs 
— Vascular  Murmurs,    -----         94 


VIU  CON"TEXTS. 

PAGE 

The  Physical  Exami.vation  of  the  Abdomex,   -  123 

Inspection, 126 

Mensuration, 128 

Palpation, 129 

Percussion,          -         -         -         -         -         -         -  132 

Auscultation,       --.....  134 

Special  Organs  :  Liver — Stomach — Spleen — Kid- 
neys— Pancreas :  Ovarian  Tumour,        -         -  134 

Appendix  :  Case  Reporting, 150 


ESSENTIALS  OF  PHYSICAL  DIAGNOSIS 
OF  THE  CHEST  AND  ABDOMEN. 

Disease  expresses  itself  in  many  forms,  but  in 
only  two  essentially  distinct  ways.  It  may 
declare  itself  to  liim  who  bears  it  or  to  him  who 
looks  on  ;  to  either  alone  or  to  both.  Its  indi- 
cations to  the  sufferer  are  now  technically 
known  as  symj^toms  ;  those  which  the  observer 
detects  are  called  signs.  It  is  with  the  latter 
alone  that  we  are  concerned  here. 

The  signs  are  not  always  on  the  surface,  nor 
are  they  always  distinctive.  On  the  contrary 
they  are  often  equivocal  and  obscure.  They 
must  therefore  be  examined,  and  their  physical 
examination  occupies  the  first  place  in  the 
inquiry.  By  means  of  a  physical  examination 
we  make  a  physical  diagnosis. 


2  ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

In  making  a  strictly  physical  examination 
it  must  be  clearly  understood  that  we  adopt 
only  physical  methods,  we  think  only  of 
phj^sical  conditions,  and  we  describe  these 
conditions  only  by  physical  terms.  We  exam- 
ine, we  think  and  speak  of  a  mechanism,  not 
an  organism.  Physical  Diagnosis  is,  therefore, 
only  a  part,  yet  a  distinct  part,  of  Medical 
Diagnosis. 

In  carrying  out  our  investigation  it  must 
always  be  carefully  borne  in  mind  that  it  is 
by  comparison  we  most  readily  and  certainly 
detect  abnormal  conditions.  We  compare  a 
corresponding  region  or  point  say,  on  each  side 
of  the  chest ;  and  if  one  alone  is  normal  we 
can  measure,  and  only  then  definitely  measure, 
the  amount  of  departure  from  the  normal  on 
the  other.  Regions  not  corresponding  may  nor- 
mally present  very  different  phj^sical  characters. 

But  although  the  normal  condition  is  not  a 
fixed  quantity,  it  varies  within  limits  that 
should  be  familiar  to  us.  From  our  phj^sical 
standpoint  they  are  fairly  definite,  and  should 
be  carefully  studied  by  us.  We  cannot  detect 
the  exception  if  we  do  not  know  the  rule. 


GENEKAL  PKINCIPLES.  3 

If  both  sides  seem  to  be  alike  abnormal  the 
student  must  be  guarded  in  his  opinion.  He 
must  remember  he  has  lost  the  only  specific 
standard,  the  corresponding  healthy  point,  that 
he  can  have.  We  refer  here  more  particularly 
to  the  examination  of  the  chest. 

We  usually  make  a  physical  examination 
by  means  of  Inspection,  Palpation,  Percussion, 
and  Auscultation ;  and  systematically  in  that 
order.  Mensuration  is  also  employed,  and 
occasionally  Succussion. 


\ 


ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 


THE  PHYSICAL  EXAMINATION  OF 

THE  LUNGS. 

For  the  purpose  of  examination  the  patient 
may  be  either  lying  in  bed  or  sitting  on  a  chair. 
If  the  former,  he  must  lie  quite  evenly  on  his 
back ;  if  the  latter,  he  should  sit  easily,  sup- 
ported lightly  by  the  back  of  the  chair.  He 
should  be  in  a  good  light  for  inspection,  and 
had  better  not  be  in  a  corner  of  the  room  or 
ward  if  careful  percussion  has  to  be  practised. 
The  apartment  should  be  of  such  a  temperature 
that  exposure  of  the  chest  will  not  prove 
injurious. 

Regions  of  the  Chest — In  order  to  make 
even  a  general  reference  to  different  parts  of 
the  chest  wall,  it  is  necessary  to  divide  it  into 
different  regions.  The  following  is  the  plan 
most  commonly  adopted  : — Anteriorly  on  each 
side  we  have  (1)  the  supra-clavicular,  in  which 
is  the  apex  of  the  lung,  rising  as  it  does  slightly 
above  the  clavicle ;  (2)  the  clavicular,  includ- 


REGIONS  OF  THE  CHEST.  5 

io^  not  more  than  the  inner  half  of  the  clavicle 
behind  which  the  lung  lies ;  (3)  the  infra- 
clavicular,  extending  from  the  clavicle  to  the 
lower  border  of  the  third  rib,  and  inwards  to 
the  edge  of  the  sternum  ;  (4)  the  mammary, 
under  the  foregoing  down  to  the  upper  border 
of  the  sixth  rib  ;  (5)  the  infra- mammary,  under 
the  mammary,  and  extending  as  far  as  the  lower 
arch  of  the  thorax. 

Centrally  there  are^  (1)  the  upper  sternal, 
and  (2)  the  lower  sternal  regions,  the  dividing 
line  being  the  horizontal  boundary  between  the 
infra-clavicular  and  the  mammary  regions  con- 
tinued inwards  to  the  middle  line. 

Laterally  there  are  (1)  the  axillary,  and  (2), 
the  infra-axillary  regions,  the  dividing  line 
being  the  horizontal  boundary  between  the 
mammar}'  and  the  infra-mammary  regions 
continued  outwards  across  this  area. 

Posteriorly  there  are  the  supra-scapular,  the 
scapular,  the  infra-scapular,  and  the  inter- 
scapular regions,  whose  relations  to  the  scapula 
are  sufficiently  indicated  by  their  names. 

For  special  reference  it  is  better  to  speak  of 
the  relation  of  the  part  to  particular  anatomical 


6  ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

points  or  lines  ;  for  example,  the  second  inter- 
costal space,  the  vertical  line  of  nipple,  the 
angle  of  the  scapula,  etc. ;  or  better  still,  we 
can  use  outline  diagrams  of  the  chest  on  which 
the  area  or  site  of  the  disease  can  be  definitely 
indicated. 

INSPECTION. 
Inspection  is  the  use  of  the  eyes  systematised. 
By  it  we  note  I.,  The  Form,  and  II.,  The 
Movements  of  the  Chest. 

I.  The  Form  of  the  Chest. 

The  ideal  normal  chest  in  the  adult  is  in  the 
form  of  an  ellipse,  the  antero-posterior  diameter 
being  much  less  than  the  transverse,  indepen- 
dently of  the  slight  curving  inwards  which 
occurs  towards  the  middle  line  posteriorly.  It 
is  perfectly  symmetrical  as  regards  the  two 
sides.  It  is  more  nearly  circular  in  the  child, 
and  tends  to  the  circular  also  in  the  adult  on 
full  inspiration.  But  we  never  meet  with  a 
chest  which  is  perfectly  regular  and  sym- 
metrical. The  predominance  of  the  right  side 
of  the  body,  and  the  accidents  of  growth  and  of 
existence  generally,  adequately  account  for  this. 


THE  RICKETY  CHEST.  7 

BILATERAL   DEFORMITIES. 

1.  The  Pigeon  Breast. — In  this  case  the  ribs 
do  not  curve  round  to  the  front  with  the  usual 
convexity  outwards,  but  straighten  forwards, 
forming  a  projecting  narrow  breast  which  the 
name  sufficiently  describes.  The  capacity  of 
the  chest  in  this  deformity,  a.s  in  the  three 
immediately  following,  is  lessened,  and  the  lung 
is  correspondingly  smaller. 

2.  The  Rickety  Chest. — It  differs  from  the 
pigeon  breast  in  having  the  ribs  not  straight- 
ened forwards,  still  less  having  a  convexity 
outwards,  but  presenting  rather  a  concavity  on 
each  side  from  their  actually  falling  in  as  they 
approach  their  articulation  with  the  cartilages. 
Nor  is  the  breast  narrow  and  projecting  as  in 
the  preceding.  Further,  there  is  that  thick- 
enino'  of  the  ends  of  the  ribs  so  characteristic 
of  rickets,  which  gives  to  the  chest  wall  on 
each  side  the  peculiar  beaded  appearance 
known  as  the  "  rickety  rosary." 

The  rickety  chest  seems  to  be  an  addition  to  the  pigeon 
breast.  In  both  there  is  a  lateral  falling  in  of  the  chest 
wall.  In  the  former  there  is  still  considerable  resistance 
in  the  ribs,  so  that  in  flattening  they  can  force  the  breast 
out  more  or  less  to  an  apex  ;  in  the  latter  the  ribs  have  less 


/ 


8  ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

resisting  power,   they  yield  more  while  the   sternum   is 
altered  less,  perhaps  not  at  all. 

8.  The  Chest  Transversely  FuTToived. — Here 
we  have  a  well  recognised  concavity  which 
runs  from  the  lower  end  of  the  sternum  down- 
wards and  outwards  a  greater  or  less  distance 
along  the  fifth,  sixth,  and  seventh  ribs,  or 
thereby.  It  varies  in  extent  of  surface  and  in 
degree  of  concavity,  but  always  affects  the 
lower  part  of  the  chest  wall,  its  inferior  limit 
corresponding  pretty  accurately  with  the  base 
of  the  lung.  The  inferior  margin  of  the  thorax, 
which,  of  course,  is  still  lower,  is  prevented 
from  falling  in  by  the  subjacent  abdominal 
viscera,  the  liver,  stomach,  and  spleen. 

The  three  varieties  of  deformity  just  men- 
tioned are  usually  brought  on  during  the  early 
years  of  childhood.  They  are  caused  on  the 
one  hand  by  diseases  which  lessen  the  resisting 
power  of  the  ribs,  notably  rickets,  and  on  the 
other  by  those  which  impair  the  expansile 
character  of  the  lung,  as  capillary  bronchitis, 
emphysema,  pulmonary  collapse ;  and  also 
paroxysmal  cough,  croup,  and  other  affections 
of  the  larynx.     If  induced  by  the  first  class  of 


MECHANISM  OF  TIIOI^ACIC  DEFOIIMITY.  9 

causes,  the  second,  or  any  of  them,  superadded, 
will  play  all  the  greater  havoc :  for  example, 
bronchitis  in  the  child  or  adult  who  already 
has  a  chest  deformed  by  rickets. 

The  mechanism  of  the  formation  of  these  deformities  is 
rather  complicated,  but  maj',  I  think,  be  simply  and  fairly 
accurately  illustrated  in  this  way.  A  toy  india-rubber 
ball,  however  flexible  the  walls,  will  expand  equally  by 
reason  of  its  elasticity  if  we  suppose  it  to  be  drawn  out- 
wards at  every  point ;  but  only  then.  If  drawn  out  at 
certain  points  it  will  fall  in  at  others.  But  if  it  have  an 
opening  it  will  not  fall  in  at  any  point,  if  the  expansile 
force,  the  size  of  the  opening,  and  the  resistance  of  its  walls 
have  a  due  relation  to  each  other.  So  it  is  with  the 
healthy  chest.  All  these  conditions  are  in  perfect  relation- 
ship. The  expcinsile  force  applied  to  the  chest  wall  is 
sufficient  to  enlarge  the  chest,  and  along  with  it  the  lungs, 
to  the  required  extent ;  the  resistance  of  the  chest  wall  is 
sufficient  to  prevent  those  parts  not  so  directly  drawn  out- 
wards from  falling  in  ;  and  the  entrance  for  the  air,  the 
wind-pipe,  is  sufficiently  free  to  prevent  the  other  two 
forces  from  being  unduly  taxed.  But  in  the  production  of 
deformity  two  of  them  are  commonly  at  fault,  the  resist- 
ance of  the  walls,  as  in  rickets,  and  the  size  of  the  oijening, 
as  in  the  obstructive  forms  of  laryngeal  disease  (croup, 
whooping  cough,  etc. ) .  On  the  same  principle  we  can  illus- 
trate the  mechanism  of  the  more  localised  depressions  such 
as  form,  for  example,  the  Chest  Transversely  Furrowed. 
There  we  have,  underlying,  a  limited  portion  of  lung  which 
will  not  expand.  The  air  is  shut  oflf  from  that  particular 
part,  and  as  the  other  parts  of  the  chest  wall  (and  lung) 
expand  on  inspiration,  that  part  necessarily  falls  in. 


10        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

Harrison's  Groove  corresponds  pretty  much  to  the  last 
mentioned  deformity,  but  Harrison  considered  that  while 
its  lower  limit  marked  the  upper  border  of  the  liver,  the 
furrow  or  sulcus  was  caused  by  the  dragging  inwards  by 
the  diaphragm  which  occurs  in  obstructed  breathing. 

4.  The  Alar  or  Pterygoid  Chest  {ala;  irrepv^, 
fyo? ;  a  wing). — This  was  recognised  by  the 
oldest  writers  as  the  chest  of  phthisis.  The 
thorax  is  small,  and  falls  forwards  owing  to  the 
increased  obliquity  of  the  ribs  which  invariably 
characterises  the  small  chest.  This  causes  the 
inferior  angle  of  the  scapula  on  each  side  to 
project  outwards  like  a  wing;  hence  the  name. 
General  and  symmetrical  diminution  in  the 
size  of  the  thorax  has  only  one  cause,  namely, 
small  size  of  the  lungs  (Jenner).  It  may  be 
that  the  lung  is  small  congenitally,  which 
rather  predisposes  to  phthisis,  or  there  may  be 
present  a  chronic  phthisis,  inducing  atrophy 
of  the  lung.  In  the  latter  case  the  contraction 
would  not  likely  be  symmetrical,  probably  not 
even  bilateral. 

We  pass  now  from  the  bilateral  contractions 
to  a  bilateral  enlargement,  namely : — 

5.  The  JEmphyseinatous  Chest. — In  hospital 
practice  this  is  the  one  common  deformity  of 


THE  EMPHYSEMATOUS  CHEST.  1 1 

the  chest  as  a  whole.  Its  characters  are  as 
conspicuous  and  well  defined  as  the  etiology 
and  pathology  of  Emphysema  itself  are 
obscure.  Ifc  should  therefore  be  carefully 
observed  and  studied  by  the  junior  student, 
though  he  may  still  know  nothing  of  the 
nature  of  the  disease  which  occasions  it.  No 
description  of  it  is  at  once  so  concise  and 
so  suggestive  as  that  of  "  the  thorax  of  per- 
manent inspiration."  Let  us  suppose  a  deep 
breath  is  taken,  and  held  in.  We  have 
then,  increase  of  the  antero-posterior  diameter 
of  the  chest,  a  more  horizontal  direction  of  the 
ribs,  increase  in  the  depth  of  the  intercostal 
spaces;  the  chest  wall  is  altogether  more 
circular  and  fixed.  These  are  just  the  char- 
acters of  the  emphysematous  chest,  and  have 
suggested  the  common  phrase,  "  the  barrel- 
shaped  chest  of  emphysema."  By  and  by  the 
sternum  becomes  arched  forwards,  and  not 
uncommonly  the  spinal  column  also.  The 
upper  two  thirds  of  the  thorax  are  alone,  or  at 
least  most  markedly,  affected  as  a  rule. 

No  doubt  it  is  true,  as  Gee  points  out,  we  can  never  by 
forced  inspiration  make  our  chest  so  circular,  etc.,  as  it  be- 


12        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

comes  from  emphysema.  But  then  we  camiot  permanently 
hold  in  our  breath.  And  Duchenne  has  shown  that  an 
exaggerated  action  of  the  inspiratory  intercostals  can  pro- 
duce a  marked  increase  of  the  antero-posterior  diameter  of 
chest,  indeed  a  very  marked  approach  to  the  circular  form. 
On  the  other  hand,  the  chest  is  contracted  in  patients 
whose  intercostals  no  longer  act. — Selections  from  the 
works  of  Duchenne,  Neio  Syd.  Soc,  1883,  pp.  58,  59. 

UNILATERAL    DEFORMITIES. 

These  Lave  a  more  direct  and  therefore  a 
more  evident  cause  than  the  deformities  we 
have  been  considering.  They  are  simply  of 
two  kinds,  Enlargements  and  Retractions. 

Enlargements  are  due  to  fluid  (pleuritic 
effusion)  or  to  air  (pneumo-thorax)  in  the 
pleural  cavity;  either  alone,  or  both  in  con- 
siderable amount.  They  may  also  be  due  to 
tumour  of  the  lung,  or  even  to  hepatic  or 
splenic  enlargement  of  some  kind,  if  it  be 
situated  low  down  in  the  thorax.  Thoracic 
enlargement  rarely  occurs,  and  if  so,  very 
slightly  in  the  pneumonic  lung,  or  from  hyper- 
trophy compensatory  to  chronic  impairment  of 
the  other  lung. 

Retractions. — One  of  the  commonest  and 
most  marked  forms  of  retraction  is  that  which 


MOVEMENTS  OF  ItESPIKATIOX.  13 

results  from  a  past  chronic  pleuritic  effusion. 
Although  the  fluid  has  disappeared,  the  lung 
may  not  expand  again,  but  remain  bound  down 
by  adhesions.  Falling  in  of  the  affected  side 
then  invariably  occurs;  the  body  inclines  to 
that  side  and  increases  the  deformity.  A  pretty 
general  and  pronounced  subsidence  of  one 
or  other  side  may  be  found  in  the  chronic 
forms  of  pulmonary  phthisis  (fibroid).  But  it 
is  the  falling  in  of  the  apices  of  the  lung  in 
ordinary  tubercular  phthisis  that  becomes  to 
the  student  a  matter  of  daily  observation  in 
hospital,  and  with  this,  therefore,  he  is 
expected  to  be  thoroughly  familiar. 

II.  The  MoYE:\rEXTS  of  the  Chest 
(of  Eespieatiox). 

We  have  now  not  merely  a  passive  condi- 
tion, but  an  active  process  to  study,  both 
normal  and  abnormal.  In  health  these  move- 
ments differ  in  the  two  sexes.  In  the  male, 
respiration  is  chiefly  abdominal  (diaphragm- 
atic) or  lower  thoracic;  in  the  female,  markedly 
upper  thoracic.  In  man  the  number  of  respira- 
tions in  the  minute  may  be  stated  at  from  14 


14        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

to  16;  in  woman  16  to  18.  The  movements 
are  regular;  each  is  gradual,  i.e.,  not  sudden, 
and,  as  regards  the  two  sides,  synchronous  and 
equal.  The  chest  circumference  on  full  in- 
spiration should  not  be  less  than  two,  and  will 
not  be  more  than  three,  inches  greater  than 
that  of  forced  expiration.  From  careful 
observation,  Walshe  thinks  that  the  duration 
of  inspiratory  movement  may  be  reckoned 
as  5,  the  expiratory  as  4,  and  the  period  of 
rest  as  1.  The  normal  pulse-respiration  ratio 
is  about  4  to  1. 

This  ratio  is  only  noteworthy  in  order  that  exceptions 
to  the  rule  which  occur  in  certain  diseases  may  be 
appreciated.  In  pneumonia,  for  example,  the  respirations 
may  be  so  increased  that  their  relation  to  the  pulse  may 
be  as  1  to  2,  but  more  commonly  it  is  as  1  to  2f  or  1  to  3. 

In  disease,  the  movements  of  respiration 
may  be  altered  as  regards  rate  and  degree ; 
there  are  also  irregularities  of  movement. 

The  rate  of  respiration  may  he  affected.  It 
is  increased  in  pleurisy  frequently  on  account 
of  the  degree  of  respiration  being  restricted 
from  the  pain.  It  is  increased  more  or  less  in 
all  febrile  conditions  when  it  is  but  a  part  of 
the  general  increased  action ;  also  in  anaemia, 


RATE  OF  RESPIRATION.  1  5 

from  the  greater  demand  for  ox3'gen,  and  very 
commonly  in  diseases  of  the  lungs  which  limit 
the  respiratory  area,  as  phthisis.  Or  the 
increase  may  be  due  to  a  pure  neurosis,  as  in 
some  cases  of  heart  disease  or  of  the  whole 
nervous  system. 

I  have  seen  a  case  in  which  the  respirations  were  quite 
70  in  the  minute,  while  the  pulse  was  under  120.  There 
was  some  obscure  neurosis  of  the  respiratory  and  other 
centres,  and  various  symptoms  usually  classed  as  hysterical. 
The  patient  was  a  middle-aged  man. 

On  the  other  hand,  the  rate  of  respiration  is 
sometimes  loiuered.  This  may  arise  mechani- 
cally from  direct  obstruction,  as  in  bronchitis, 
asthma,  etc.  In  asthma  the  difficulty  is  chiefly, 
and  I  have  known  it  to  be  exclusively,  with 
expiration.  The  respiration  is  slower  also  in 
many  cases  of  head  injury,  apoplexy,  coma, 
etc.,  from  diminished  sensibility  of  the  respira- 
tory centres. 

The  degree  of  respiratory  movement  may  he 
affected.  It  may  be  limited  by  pain,  as  in 
pleurisy,  and  then  the  rate  will  be  increased, 
as  we  have  just  said.  It  may  be  limited  in 
these  neuroses  also  in  which  the  rate  is 
increased.      Respiration,    again,   is    restricted 


1 6        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

under  conditions  which  mechanically  slow  it, 
as  in  bronchitis,  emphysema,  pulmonary 
oedema,  asthma,  and  laryngeal  obstruction. 

But  the  more  striking  and  simpler  forms  of 
limited  movement  are  those  which  are  uni- 
lateral or  partial.  The  impaired  expansion  of 
the  phthisical  apex,  or  apices,  accompanies,  or 
it  may  be  precedes,  the  permanent  subsidence 
of  the  part  already  referred  to.  There  is 
diminished  expansion  of  the  affected  side  in 
pneumonia,  pleuritic  effusion,  and  pneumo- 
thorax, and  generally  in  those  cases  where 
there  is  subsidence  of  the  chest  wall. 
Sudden  and  complete  cessation  of  respira- 
tory movement  on  both  sides  can  hardly 
arise  from  anything  except  paralysis  of  the 
respiratory  centres,  and,  occurring  without 
obvious  explanation,  would  point  to  the 
probability  of  haemorrhage  having  occurred 
into  the  medulla  or  neighbouring  parts. 

The  respiration  may  he  irregular.  It  may 
be  wholly  thoracic,  or  it  may  be  wholly 
abdominal.  There  may  be  retraction  when 
and  where  we  would  expect  expansion.  The 
rhythm  may  be  altered. 


IKREGULAKITTES  OF  KESI'IKATION.  17 

(a)  Respiration  will  be  wholly  abdominal 
when  there  is  paral3''sis  of  the  thoracic  muscles 
of  respiration.  The  diseases  in  which  this 
may  occur  are  usually  of  the  spinal  cord,  and 
require  separate  study ;  but  it  will  be  remem- 
bered that  so  long  as  the  lesion  does  not  extend 
upwards  beyond  the  6th  or  5th  cervical  nerves, 
the  phrenic  will  maintain  abdominal  respira- 
tion. 

(b)  Respiration  will  be  wholly  thoracic  when 
there  is  paralysis  of  the  diaphragm.  If  it  be 
a  true  nervous  paralysis,  it  will  be  a  part, 
probably  the  last  stage,  of  a  more  general  form, 
as  in  progressive  muscular  atrophy.  But  the 
paralysis  may  be  of  inflammator}?"  origin,  as  in 
diaphragmatic  pleurisy,  or  it  may  be  from 
mechanical  pressure,  as  in  ascites. 

(c)  We  not  unfrequently  notice  that  with 

inspiration  there  is  intercostal  retraction  or 

furrowing,  particularly  in  the  lateral  aspects 

of  the  lower  thorax.     It  may  be  that  even  the 

lower  ribs  and  uniform  cartilage  are  drawn  in. 

This  will   occur    unilaterally  and    bilaterally 

under   exactly   those    conditions    which    are 

causing,  or  have  caused,  the  permanent  retrac- 

B 


18        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

tions  of  the  chest   wall   to   which   we  have 
already  referred  (Pulmonary  Collapse). 

(d)  The  rhythm  of  respiration  may  be 
altered.  What  is  known  as  Cheyne-Stokes  re- 
spiration virtually  represents  this.  It  may  be 
shortly  described  as  a  gradual  recession  of  the 
respiratory  movement  and  rate  till  it  seems 
as  if  breathing  had  altogether  ceased,  when  it 
faintly  reappears,  and  as  gradually  progresses 
till  the  respiration  becomes  in  turn  rather  un- 
duly marked.  The  same  cycle  is  repeated 
again  and  again,  each  occupying  one  to  two 
minutes.^  It  was  first  described  by  Cheyne  of 
Dublin  in  1818,  and  again  by  Stokes  in  1846. 
It  occurs  in  conditions  of  coma,  and,  folio  wing- 
Stokes'  view,  is  held  to  be  specially  related  to 
fatt}''  degeneration  of  the  heart,  though  in 
what  way  is  not  known. 

In  its  typical  form,  as  described  by  Cheyne  and  Stokes, 
this  phenomenon  is  as  rare  as  it  is  common  in  its  grosser 
forms.  In  comatose  states,  however  induced,  the  patient 
may  be  observed  to  breathe  slower  once  or  twice,  appear 
to  stop  altogether,  breathe  again  hurriedly  a  few  times, 
and  then  gradually  fall  into  the  fainter  and  arrested 
respiration  as  before.  It  may  be  observed  in  this  modified 
form  during  deep  yet  normal  sleep  ;  also  in  dying  by  coma. 


MEASUREMENT  OF  THE  CHEST.  19 

It  depends  simply  ou   a  diminished  sensibility  of    the 
respiratory  centres. 

{(')  Respiratory  movements  should  be  gradual.  In  cer- 
tain asthenic  forms  of  pulmonary  disease,  I  have  noticed  a 
peculiar  bounding  movement  of  inspiration  which,  in  the 
first  instance,  was  forced  upon  ray  attention  by  the  sudden 
impulse  conveyed  to  my  ear  by  the  stethoscope  when 
auscultating.  I  have  not  been  able  to  assign  to  it  any 
special  significance.  It  is  something  like  the  gasping 
respiration  of  extreme  asthenia,  but  I  have  noticed  it  when 
the  patient  was  still  able  to  walk  some  distance  out  of 
doors. 

ISIENSUEATION. 

We  may  here  interpolate  the  few  remarks 
we  intend  to  make  with  regard  to  mensuration. 
All  the  foregoing  deformities  can,  for  practical 
purposes,  be  sufficiently  appreciated  by  the 
eye.  This  would  be  true  even  were  mensura- 
tion reduced  to  a  more  simple  and  convenient 
art  than  it  has  yet  been.  There  is,  however 
a  general  agreement  that,  by  the  following 
simple  modification  of  Woillez's  cyrtometer, 
the  shape  of  the  chest  wall  at  any  particular 
level  can  be  accurately  enough  taken.  Two 
pieces  of  soft  metal  gas  pipe  are  united  at  one 
end  in  such  a  way  as  to  form  a  hinge.  Placing 
this  hinge  at  the  middle  line  posteriorly,  the 


20        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

flexible  pipe  is  brought  round  each  side  of  the 
chest,  being  at  the  same  time  carefully  moulded 
to  the  chest  wall,  so  as  to  take  a  cast,  as  it 
were,  at  that  particular  level.  The  hinge 
admits  of  it  then  being  opened,  and  again  laid 
in  position  on  a  piece  of  paper,  and  an  accurate 
tracing  of  it  made.  Double  tape  measures  are 
also  to  be  had  hy  which  the  circumference  of 
the  two  sides  can  be  taken  and  compared  at  the 
same  time,  although  an  ordinary  tape  line  will 
suffice  if  we  carefully  mark  the  middle  line 
behind  and  in  front. 

PALPATION. 

When  we  have  completed  a  careful  exa.mina- 
tion  by  means  of  the  eye,  the  next  step, 
naturally,  is  to  corroborate  or  correct  our  im- 
pressions by  means  of  the  hands  placed  on  the 
chest  wall.  This  is,  in  the  main,  the  use  of 
palpation.  It  should  follow  inspection,  yet  go 
hand  in  hand  with  it.  To  take  a  very  com- 
mon case.  A  patient  is  suspected  to  have 
incipient  phthisis.  The  apices  seem  to  be 
flattened.  Facing  the  patient,  with  our  hands 
placed   above  the   shoulder,  the   thumbs  are 


VOCAL  FREMITUS.  21 

brought  round  to  the  frout,  and  placed  on  the 
infra-clavicular  regions.  With  a  little  ex- 
perience the  degree  of  expansion  can  in  this 
way  be  appreciated  with  the  greatest  nicety ; 
or  the  same  thing  may  be  done  by  standing 
behind  the  patient  with  the  fingers  placed  on 
the  apices.  And  we  are  reminded,  perhaps, 
of  the  difference  between  a  ph3'sical  and  a 
more  general  examination.  The  patient  may 
present  the  general  symptoms  and  signs  that 
suggest  pulmonary  mischief,  but  the  ample  and 
equal  expansion  on  both  sides  tells  us  that 
there  is,  not  yet  at  least,  any  appreciable  en- 
croachment of  the  respiratory  area.  Conversely 
the  fever,  cough,  and  lassitude  may  long  since 
be  gone  and  forgotten,  yet  the  imperfect  ex- 
pansion of  one  apex  tells  its  own  tale  of  a  past 
and  incurable  physical  disability.  Indepen- 
dently of  inspection,  palpation  as  a  test  of 
pulmonary  disease  is  usually  employed  with 
but  one  object,  namely,  to  estimate  what  is 
known  as  the  : — 

Vocal  Fremitus,  or,  as  it  is  familiarly 
shortened,  the  V.Fr.  The  Vocal  Fremitus  is 
the  voice  vibration  which  is  conveyed  to  the 


22        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

chest  wall,  and  we  estimate  its  amount  by- 
placing  the  hand  lightly  on  different  parts  of 
the  chest.  What  we  said  at  the  outset  about 
comparative  rather  than  absolute  conditions 
being  the  basis  of  our  conclusions  is  particu- 
larly true  regarding  the  V.Fr.  There  are  so 
many  circumstances  common  to  both  sides, 
and  quite  within  healthy  limits,  which  make 
it  vary  in  different  individuals.  Of  these  the 
chief  are  (1)  the  quality  (timbre)  and  pitch  of 
the  voice,  and  (2)  the  amount  of  soft  tissue, 
fat  especially,  on  the  chest  wall.  A  rich  full 
voice  and  lower  tones  cause  greater  fremitus, 
and  so  of  course  will  a  thin  chest  wall.  It 
is  naturally  more  marked  on  the  right  than 
on  the  left  side,  where  the  heart  breaks  in 
some  degree  the  sound  waves. 

In  testing  the  vocal  fremitus,  it  is  best 
always  to  make  the  patient  repeat  the  same 
sound.  The  numbers  23,  24,  are  commonly 
used,  but  98,  99,  are  better  sounds,  as  they 
give  a  purer  open  vowel  tone. 

In  disease,  the  V.Fr.  is  determined  practi- 
cally by  the  same  conditions  which  influence 
the  vocal  resonance,  a  test  which  we  shall  take 


PLEURAL  FREMITUS.  23 

iipby  and  by.  It  will  bo  the  moi'c  distinct, 
the  more  uniform  the  medium  by  which  it  is 
conveyed  to  the  chest  wall.  Pulmonary  con- 
solidation, therefore,  such  as  occurs  in  the 
course  of  tubercular  disease  and  pneumonia, 
increases  it.  It  may  be  increased  over  the 
upper  areas  of  the  chest  where  there  is  pleuritic 
effusion  below.  A  superficial  cavity  in  the 
lung,  if  it  opens  freely  into  a  pretty  large 
bronchus,  will  give  distinctly  increased  vocal 
fremitus. 

On  the  other  hand,  if  the  medium  is  com- 
plex, as  when  there  is  fluid,  or  even  air,  in  the 
pleural  cavity,  the  V.Fr.  will  be  diminished, 
or  it  may  be  absent.  As  an  exceptional  cir- 
cumstance, however,  it  is  well  to  know  that 
vocal  fremitus  may  sometimes  be  carried  to  the 
right  base  posteriorly,  even  when  there  is  a 
considerable  amount  of  fluid  in  the  pleural 
cavity  (Walshe). 

Pleural  FTer)iitus  is  the  vibration  conveyed 
to  the  chest  wall  from  a  roughened  pleural 
surface.  It  indicates  an  unusual  degree  of 
alteration  of  surface,  a  coarse  roughness,  which 
is  likely  felt  by  the  patient  himself,  who  may 


24        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

be  the  first  to  call  attention  to  it.  If,  as  it 
usually  is,  of  pleuritic  origin,  it  will  probably 
indicate  a  later  stage  of  the  disease  when 
absorption  has  to  a  great  extent  taken  place, 
and  the  now  very  roughened  surfaces  brought 
once  more  into  contact.  As  we  shall  see  again, 
in  speaking  of  friction  sound  (page  71),  it  is 
most  commonly  made  out  over  the  lateral 
region,  or  round  by  the  back.  Alterations  of 
the  pleural  surface  from  other  causes  are  very 
rare,  but  they  may  occur  as  the  result  of 
tubercle  or  cancer  of  the  part,  and  occasion 
distinct  fremitus. 

Bronchial  Fremitus  is  the  vibration  set  up 
by  an  abundant  mucous  secretion  in  the 
larger  bronchi.  It  is  readily  altered  or  made 
to  disappear  by  coughing.  Children  present 
it  frequently,  and  very  often  it  is  supposed  by 
the  parents  to  indicate  serious  mischief.  But, 
like  the  coarser  mucous  rales,  it  simply  indi- 
cates a  free  bronchial  exudatio^ 

PEECUSSION. 
With  the  exception  of  an  incidental  refer- 
ence to  one  or  two  diseases,  we  have  hitherto 


PERCUSSION.  25 

been  considering  simple  physical  conditions, 
and  we  have  been  describing  them  in  common 
terms.  When  we  come  to  percussion  it  is 
different.  We  meet  now  with  thin2:s  that 
cannot  be  described  in  common  terms.  Prob- 
ably before  the  student  has  opened  a  book  on 
medicine  he  has  tried  his  hand  at  percussion, 
and  has  already  attached  some  meaning  to  the 
terms  "  clear  percussion "  and  "  dull  percus- 
sion." But  it  has  not  likely  occurred  to  him 
that  he  is  not  usino-  these  terms  in  their 
ordinary  sense.  In  any  case  he  is  not,  and  he 
should  understand  that  at  the  outset.  Not 
that  he  is  to  trouble  himself,  because  "  dulness 
and  clearness  are  not  admitted  among  the 
properties  of  sound  by  acoustic  philosophers." 
But  he  should  understand  before  goino;  further 
that  these  words  are  mere  conventional  terms 
which  are  current  among  us  because  they  are 
short  and  handy.  To  get  the  impressions 
themselves,  he,  all  of  us,  must  listen,  and, 
having  got  them,  I  think  we  may  express 
them  b}^  any  terms  that  are  agreed  upon. 

How  is  the  student  to  listen  ?     He  must  first 
know  how  to  produce  the   sounds;   he  must 


26        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

know  how  to  percuss.  The  most  simple  and 
obvious  method  is  by  striking  the  chest  wall 
with  one  hand,  or  by  the  fingers  of  one  hand. 
This  is  known  as  immediate  percussion.  It 
was  this  form  that  was  adopted  by  Aven- 
brugger,  who  first  systematically  practised 
and  described  percussion  (1761),  but  it  is 
not  now  employed,  except  in  the  case  of  the 
clavicle,  which  we  still  percuss  directly. 

Mediate  percussion  is  therefore  now  always 
understood  when  we  speak  of  percussion.  It 
may  be  practised  either  by  the  use  of  the 
fingers  simply,  or  by  means  of  certain  instru- 
ments. Piorry,  the  distinguished  pupil  of 
Laennec,  invented  what  is  known  as  the 
plexirtieter,  a  small  plate  of  wood,  more 
commonly  now  of  ivory,  which  is  applied  to 
the  chest  wall,  and  receives  the  stroke  from 
the  fingers  of  the  right  hand.  It  is  too  com- 
mon to  need  description.  So  is  the  hammer 
of  Barry ,^  by  which  the  percussion  stroke  may 
be  given,  and  to  the  use  of  which  Piorry  also 
gave  the  weight  of  his  authority. 

1  Generally  but  incorrectly  ascribed  to  Wintrich  (1841), 
But  Piorry,  in  Ms  Percussion  Mid'mle  (1828),  refers  to  and 
describes  the  little  hammer  of  M.  Barry. 


METHOD  OF  PERCUSSION.  27 

The  prevailing  opinion,  however,  in  our 
country,  and  also  on  the  Continent,  is  in  favour 
of  the  use  of  the  fingers  alone.  Even  mechani- 
cally the  fingers  are  well  adapted  to  bring  out 
tlie  chest  sound  best,  at  the  same  time  causing 
the  least  sound  themselves  on  being  struck ; 
while,  by  the  sense  of  touch  impressions  are 
caught  as  we  percuss,  which  materially  aid  the 
sense  of  hearing.  Further,  the  fingers  can 
better  adapt  themselves  to  the  chest  wall  than 
any  one  form  of  pleximeter  can. 

Method  of  Peecussiox. 

The  student  has  now  to  consider  how  he  is 
to  use  his  fingers  on  percussing.  If  he  is 
naturally  "neat  handed,"  he  will  soon  percuss 
neatly,  whether  he  strike  with  one  or  two 
fingers,  whether  these  are  the  first  and  second, 
the  second  and  third,  or  the  whole  three. 
Obviously  the  stronger  the  stroke  that  is 
needed,  the  greater  must  be  the  number  of 
fingers  that  he  employs.  He  should,  however, 
practise  on  the  following  lines. 

Aim  at  freedom  in  the  use  of  the  fingers 
so  that  any  can  be  user]  if  necessary.     Always 


28         ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

percuss  from  the  wrist,  or  in  exceptional  cases 
where  a  strong  stroke  is  needed,  with  a  slight 
movement  of  the  forearm.  Strike  with  the 
points  of  the  fingers,  and  as  nearly  perpen- 
dicularly as  the  nails  will  allow.  Let  the 
percussing  finger  rebound  gently  from  the 
finger  struck :  it  does  not  follow  that  it  need 
be  what  is  called  in  music  a  staccato  move- 
ment. Let  the  stroke  be  always  the  lightest 
that  satisfies  the  practised  ear,  i.e.,  the  stu- 
dent's own  ear,  when  he  has  had  some  ex- 
perience to  guide  him. 

Here  we  may  note  a  modification  of  this 
last  rule.  The  strength  of  the  stroke  must 
depend  also  on  whether  he  is  examining  a 
superficial  or  a  deep  structure.  Light  per- 
cussion tries  the  former  ;  strong  percussion, 
the  latter.  A  good  example  of  the  use  of  the 
two  methods  is  afibrded  where  the  transverse 
colon  lies  in  part  over  the  lower  border  of  the 
liver.  If  we  percuss  lightly  we  get  only  the 
"  tympanitic "  note  (a  term  to  be  explained 
immediately)  of  the  intestine ;  if  we  percuss 
strongly  we  bring  out  the  duller  liver  tone. 

The  same  freedom  in  placing  the  fingers  of 


STUDY  OF  PERCUSSION.  29 

the  left  hand  on  the  chest  wall  is  desirable. 
If  light  percussion  or  any  detailed  inquiry  is 
wanted,  one  finger  alone  as  a  pleximeter  is 
best,  the  others  being  raised  from  the  surface 
of  the  chest.  We  can  often  conveniently 
compare  adjacent  parts  by  having  all  the 
fingers  outspread  in  contact  with  the  surface 
while  we  percuss  each  in  turn,  but,  as  a  rule, 
the  percussion  medium  should  be  small.  The 
pressure  should  be  always  moderate  and  equal. 
When  deeper  structures  are  under  examina- 
tion we  not  only  percuss  with  greater  force, 
but  we  also  make  firmer  pressure  with  the  left 
hand.  The  posture  of  the  patient  has  been 
already  referred  to  (p.  4),  and  also  the  ob- 
jection to  having  the  patient  in  a  corner  of 
the  room. 

We  come  now  to  the  question,  How  is  the 
student  to  listen  ?  We  have  pointed  out  that 
the  various  sounds  cannot  be  described  bv  so 
many  terms,  and  that  he  must  listen  for  him- 
self. How  should  he  begin  ?  By  listening 
to  the  sounds  brought  out  from  the  normal 
chest  by  his  teacher,  and  by  trying  for  him- 
self the  percussion   note    of  common   objects 


30        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

around  liim.^  Broad  contrasts  that  can 
easily  be  described  are  first  elicited.  He 
then  passes  to  finer  distinctions  that  can  only 
be  appreciated,  not  expressed.  He  will  learn 
that  what  cannot  be  described  absolutely  can 
be  stated  comparatively.  He  will  say  that 
this  note  is  rather  clearer,  or  more  hollow, 
or  more  solid  than  the  other. 

Percussion  Sounds. 

Before  going  further  it  will  be  well,  in  a 
sentence  or  two,  to  make  some  reference  to 
sound  itself,  and  to  the  acoustic  terms  we 
employ.  Although  the  student  need  not,  as 
we  have  already  said,  make  a  special  study 
of  higher  acoustics,  still  he  ought  to  know 
enough  about  sound  to  enable  him  to  use 
certain  terms  with  an  accuracy  sufiicient  for 
the  purposes  of  his  present  study. 

When  a  sound  is  heard  the  question  first 
of  all  arises,  What  is  its  amount  or  inten- 
sity ?      What  is  its  strength  ?      We  consider 

^  All  students  of  Gairclner  will  remember  how,  on  that 
solid  foundation,  he  based  his  academic  treatment  of  the 
subject  of  percussion. 


PERCUSSION  SOUNDS.  31 

this  question  of  degree  as  ranging  between 
stronor  and  weak,  loud  and  faint.  Then  we 
have  the  quality  of  a  sound.  It  may  be  a 
mere  noise  or  it  may  be  a  musical  tone. 
And  the  quality  of  both  a  noise  and  a  tone 
may  be  very  different.  A  block  of  wood  on 
being  struck  gives  a  different  quality  of  noise 
from  a  bar  of  iron ;  a  cornet  gives  a  different 
quality  of  tone  from  a  violin.  And  this 
difference  of  quality  is  recognised  even  though 
the  same  note  be  played  on  each ;  for  musi- 
cal tones,  and  they  alone,  have  still  another 
character,  namely,  lyitcli.  This  refers  to  the 
position  the  tone  occupies  in  the  musical 
scale  :   it  may  be   high   or  low.^      It  will   be 

^  A  sound  is  musical  when  the  wave  impulses  which 
constitute  the  sound  repeat  themselves  with  perfect  regu- 
larity. The  uniform  and  equal  repetition  is  pleasing  to  us. 
A  noise,  on  the  other  hand,  is  simply  a  jumble  of  impulses. 
"They  dash  confusedly  into  the  ear,"  as  Tyndall  says, 
"and  reproduce  their  own  unpleasant  confusion  in  our 
sensations."  The  intensity  or  loudness  of  a  sound  is  quite 
another  matter.  It  depends  on  the  width  or  amplitude  of 
the  waves.  A  smooth,  round,  small  stone  let  fall  gently 
into  the  water,  will  cause  a  regularly  repeating  series  of 
waves  which  correspond  to  a  musical  tone  ;  a  similar  large 
stone  would  simply  make  larger  waves  of  the  same  kind, 
which  would  correspond  to  a  louder  tone.     A  handful  of 


32         ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

convenient  for  us  also  to  speak  of  the  re- 
sonance of  a  tone.  It  can  hardly  be  included 
strictly  under  quality ;  at  least,  it  is  not  the 
primary  sound  that  is  referred  to  by  this 
term,  but  the  resound,  the  resounding.  But 
in  practice  it  must  be  considered  as  an  ele- 
ment in  the  quality  of  a  tone.  We  are  also 
accustomed  to  speak  of  a  tympanitic  note. 
It  approaches  a  musical  tone  ;  but,  indeed,  it 
requires  no  description  if  we  remember  its 
origin.  It  is  the  note  of  tympanitis,  an  an- 
cient word  for  a  o-aseous  distension  of  the 
abdominal  viscera.  It  is  the  note  given  by 
a  distended,  but  not  over-distended,  stomach 
or  transverse  colon. 

Perhaps  the   following   illustration   of   dif- 

gravel  thrown  into  the  water  will  correspond  to  a  noise  ; 
a  cartful  of  gravel,  to  a  louder  noise. 

A  simple  illustration  will  show  us  further  how  loudness 
differs  from  lyitch.  Every  one  knows  that  a  pendulum  of 
a  given  length  swings  a  certain  number  of  times  whether 
the  length  of  the  siving  be  great  or  small.  But  if  we  alter 
the  length  of  the  joendulum,  we  alter  the  numher  of  swings 
in  a  given  time  ;  the  rate  of  vibration  is  changed.  And 
pitch  depends  simply  on  rapidity  of  vibration.  The  length 
of  the  swing  then,  determines,  as  it  were,  the  loudness  ; 
the  length  of  the  pendulum,  the  pitch. 


PERCUSSION  SOUNDS.  33 

ferent  tones  will  uot  be  the  less  suorrrestive 
that  it  is  homely.  If  we  strike  an  old,  dis- 
used rain-barrel  it  will  give  a  sound  whose 
intensity  is  determined  by  the  force  of  the 
stroke,  but  it  will  be  a  noise  at  the  best. 
There  will  be  little  musical  quality  about  it 
and  no  pitch.  But  suppose  one  in  good 
order  and  ready  for  use.  It  will  give  a  tone 
of  a  comparatively  musical  quality,  along 
with  a  laro'e  deo:ree  of  resonance.  We  miMit 
call  it  a  low  tympanitic  note.  Now  fill  it 
one  third  full  of  water.  Below  the  water 
line  we  get  no  tone  or  sound,  bej^ond  that  of 
the  stroke  on  our  hand  which  is  acting  as  the 
pleximeter.  Above  the  water  line  there  will 
be  less  resonance  than  before ;  we  would  call 
it  duller;  and  the  pitch  will  be  higher.  The 
note  may  still  be  t^^mpanitic.  Fill  it  two 
thirds  full  of  water,  and  above  the  water 
line  we  get  still  less  resonance ;  the  tone 
will  be  yet  higher  in  pitch,  but  altogether 
more  imperfect ;  it  may,  indeed,  have  resolved 
itself  into  a  mere  noise.  It  will  not  now 
give  exactly  the  impression  of  a  tympanitic 
qualit}^,  but  very  probably  one  that  is  partly 


34        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

tympanitic  and  partly  dull,  a  tone  that  is  not 
uncommonly  met  with  in  the  affected  chest, 
and,  as  we  shall  see  shortly,  is  termed  the 
duU-tympanitic  note.  That,  however,  is  a 
sound  which,  like  so  many  others,  must  be 
heard  in  a  patient  before  it  can  be  in  any 
practical  sense  understood. 

Sometimes  a  "  wooden  note  "  or  "  wooden 
resonance"  is  spoken  of  to  describe  a  sound 
which  is  not  unfrequently  heard  in  certain 
morbid  states.  It  has  something  of  the  char- 
acter which  its  name  indicates. 

But  the  dull-tympanitic  note  is  the  basis 
of  another  of  a  much  more  defined  character, 
the  name  of  which  is  at  once  felt  by  even 
the  beginner  to  be  remarkably  appropriate, 
that  is,  the  cracked-pot  sound  {Bruit  de 
p)ot  fSle).  It  was  described  first  by  Laennec, 
who  compared  it  to  the  sound  given  out  by 
a  broken  jar.  He  considered  that  a  pul- 
monary cavity  was  essential  to  its  produc- 
tion. Shortly  afterwards,  apparently  first  by 
Raynaud  and  Piorry,.  it  was  compared  to 
the  sound  produced  by  striking  the  closed 
hands  on  the  knee,  and  this  has    been    ac- 


THE  CRACKED-POT  SOUND.  35 

cepted  and  copied,  so  far  as  I  kuow,  by  every 
writer  on  the  subject,  whether  British,  Con- 
tinental, or  American. 

The  clinking,  hissing  sound  produced  by  striking  the 
clasped  hands  on  the  knees  seems  to  rae  a  very  misleading 
comparison.  The  hissing  quality  is  not  an  essential  ele- 
ment, I  venture  to  say  is  not  an  element  at  all,  of  the  true 
cracked-pot  sound,  I  tluiik  the  dull-tympauitic  note  is 
solely  and  quite  evidently  the  basis  of  the  cracked-pot 
sound  in  its  common  form,  whether  arising  from  its  com- 
mon cause,  or  exceptionally,  above  the  dulness  of  pleuritic 
effusion  or  of  pneumonia.  But  I  have  never  heard  that 
simple  form,  what  one  might  call  the  classical  form,  in 
bronchitis  or  in  the  crying  child  :  and  Walshe  admits  it  is 
not  quite  the  same  in  the  latter.  This  bronchitic  form, 
which  is  heard  very  readily  iu  the  young  suffering  from 
bronchial  catarrh,  and  which  disappears  with  the  catarrh, 
approaches  rather  the  "  humoral "  sound  of  Piorry,  some- 
times obtained  on  percussing  a  cavity  containing  both 
liquid  and  air. 

A  further  development  of  the  above  sound, 
and  altogether  rarer  is : — 

The  Metallic  Ring.  If  the  cracked-pot 
sound  has  for  its  basis  the  dull -tympanitic 
note,  the  metallic  rino-  is  founded  on  the 
amphoric  note,  a  sound  which  will  be  re- 
ferred to  later  (p.  43).  Laennec  recognised 
the  metallic  character  of  the  cracked- pot 
sound  also,  and  this  view  has  always  been 


36        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

accepted ;  but  since  his  time  authorities  have 
employed  the  term  metallic  ring  to  signify  a 
tone  with  less  crack  and  more  ring. 

The  difficulties  of  the  students  have  been  immeasurably 
increased  by  attempted  descriptions  of  fine  distinctions, 
and  by  a  varied  nomenclature  and  classification.  These 
sounds  are  as  impossible  to  describe  as  they  are  easy  to 
grasp  if  once  actually  heard.  They  shade  off  into  uncer- 
tain sounds  in  many  instances,  but  if  once  the  typical 
forms  are  heard  a  few  times  they  can  hardly  be  forgotten. 

Method  of  Percussion — {continued). 

With  these  few  observations  on  sound  it- 
self, and  on  the  various  percussion  terms  we 
employ,  let  us  continue  from  page  30  our 
method  of  estimating  the  different  sounds 
which  we  hear  over  the  chest.  We  have 
seen  that  sounds  which  cannot  be  described 
absolutel}^  may  be  stated  comparatively.  The 
student  should  remind  himself  once  more 
that  it  is  only  by  careful  comparison  that 
he  can  appreciate  the  slight  departures  from 
the  normal.  Passing  from  the  percussion  of 
different  objects  around  him,  to  which  we 
have  already  referred,  he  will  still  educate 
his  ear  with  the  broad  distinctions  found  in 


METHOD  OF  PERCUSSION.  37 

the  human  subject.  The  })ercussion  note  of 
the  liver  will  seem  absolutely  dull  compared 
with  that  of  the  infra-clavicular  region,  but 
it  is  not  so  devoid  of  all  resonance  as  the 
thisrh.  He  will  find  that  the  note  of  the 
precordial  region  comes  between  that  of  the 
liver  and  the  lung.  Trying  next  the  pure 
pulmonary  sound  it  will  seem  to  him  the 
acme  of  clearness,  but  he  passes  to  the  half- 
distended  stomach  and  finds  that  it  is  even 
clearer,  and  that  it  has  some  other  quality  in 
addition ;  but  what  to  call  this  will  be  his 
difficulty,  unless  the  word  '•'  tympanitic " 
occurs  to  him.  Lastly,  he  goes  back  again 
to  the  lung  sound,  and  it  seems  now  to  be 
just  a  little  dLill.  He  will  thus. learn  how 
difficult  it  must  be  to  retain  in  one's  mind 
an  absolute  impression  of  the  natural  tone  of* 
difi"erent  parts,  and  how  greatly  he  must  de- 
pend on  the  comparison  of  corresponding 
points  on  the  two  sides.^ 

^  Piorry  attempted  to  fouud  a  standard  nomenclature 
based  on  the  natural  percussion  note  of  different  parts  of 
the  body  ;  for  example  le  son  femoral,  jecoral,  cardial,  jnil- 
monal,  etc.  But  it  proved  equally  needless  and  impractic- 
able. 


38      essentials  of  thysical  diagnosis. 

Percussion  of  the  Lungs  in  Health. 

The  student  will  probably  begin  with  the 
percussion  of  the  upper  chest  in  front.  In  any 
case  he  had  better  commence  by  percussing 
corresponding  points  on  each  side  and  compare 
them  carefully  as  already  explained.  He  may 
then  take  a  more  general  survey  of  a  particular 
region  and  compare  it  with  the  corresponding 
region  in  the  same  way.  In  some  cases  he 
might  take  this  method  first.  But  whatever 
plan  he  adopts  he  must  see  that  all  the  con- 
ditions are  similar.  For  example,  there  should 
be  the  same  kind  of  stroke,  especially  as 
regards  strength,  the  same  finger  or  fingers 
applied  to  the  chest,  and  he  will  not  place  one 
in  and  parallel  with  an  intercostal  space  on  one 
side  and  across  a  rib  on  the  other. 

It  will  be  observed  that  apart  altogether 
from  the  precordial  region  the  percussion  note 
is  not  the  same  at  all  parts.  Let  the  clavicle 
itself  be  percussed,  and  it  will  be  found  that 
the  outer  half  is  duller  than  the  inner,  while 
again  it  becomes  less  resonant  at  the  sternal 
articulation.     Over  the  infra-clavicular  region 


PERCUSSION  OF  THE  HEALTHY  LUNG.         30 

there  is  less  resonance  and  more  resistance 
towards  the  sternum,  till  we  find  we  are 
catching  the  dulness  of  the  great  vessels  of  the 
mediastinum.  But  such  details  are  not  to  be 
committed  to  memory  from  books  ;  they  are  to 
be  sought  out  by  each  one  for  himself,  not  so 
much  as  facts,  as  contributing  to  the  great 
principle  that  such  differences  occurring  even 
over  the  same  parts  in  different  healthy 
individuals,  demand  not  an  absolute,  but  a 
comparative  standard. 

But  the  general  features  of  the  different 
regions  should  have  some  attention  from  the 
first.  The  right  mammary  region,  with  its 
commencing  liver  dulness,  and  the  right  infra- 
mammary,  where  that  dulness  is  more  marked  ; 
the  cardiac  dulness  of  the  left  mammary 
region,  and  the  stomach  tympanitic  note  of 
the  left  infra-mammary,  should  all  be  examined. 
But  we  reserve  their  detailed  description  till 
we  come  to  the  physical  examination  of  the 
respective  organs. 

We  would  just  add  that  the  student  must 
be  prepared  to  find  the  percussion  of  the 
upper  part  of  the  posterior  surface  of  the  chest 


40        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

comparatively  unsatisfactory,  at  least  over  the 
scapula?.  It  is  difficult  or  impossible  to  make 
out  finer  distinctions  over  them,  where  the 
percussion  stroke  itself  requires  to  be  so  much 
stronger  to  penetrate  the  greatly  thickened 
parietes  at  that  part.  But  he  will  have  no 
difficulty  with  broader  contrasts,  and  the  finer 
will  usually  be  sought  for  in  front. 

Percussion  of  the  Lungs  in  Disease. 

A  mere  enumeration  of  the  more  ordinary 
diseases  that  lead  to  an  alteration  in  the  per- 
cussion of  note  will  here  suffice.  A  full 
discussion  belongs  rather  to  the  study  of  the 
diseases  themselves,  and  rarer  conditions  may 
profitably  be  left  out  of  account  till  the  more 
common  examples  are  thoroughly  mastered. 
There  may  be  : — 

(a)  Complete  absence  of  resonance,  or  abso- 
lute dulness.  This  usually  arises  from  fluid 
in  the  pleural  cavity  (pleuritic  effusion, 
hydro-thorax)  ;  if  it  does  not,  it  would  suggest 
a  tumour,  or,  if  over  the  upper  front  of  chest, 
to  the  right  of  the  middle  line  especially,  an 
aortic  aneurism  near  the  surface. 


HYPER-RESONANCE.  41 

(b)  Dhninished  resonance,  or  simply,  dul- 
ness.  The  slight  consolidation  of  incipient 
phthisis  in  the  apex  is  the  common  cause  of  the 
least  pronounced  forms.  In  its  more  pronounced 
forms  it  may  arise  from  tubercular  or  pneu- 
monic consolidation;  from  the  serous  infiltra- 
tion of  pulmonary  oedema ;  from  fibro-plastic 
exudation  (false  membrane)  in  pleurisy  without 
effusion ;  from  pneumo-thorax,  if  the  distension 
is  extreme  ;  or  from  aneurisms  not  very  large 
or  very  near  the  surface. 

(c)  Increased  resonance,  or  liyjper-resonance. 
A  hyper-resonant  qualit}^  of  percussion  note 
is  not  common.  Emphysema,  pneumo-thorax 
(where  the  distension  is  moderate),  pulmonary 
collapse  and  atrophy,  are  possible  causes,  but 
then  the  note  is  apt  to  be  altered  in  character 
in  the  direction  of  the  t^anpanitic  quality. 
Perhaps  the  most  undoubted  cause  of  pure 
hryper-resonance  is,  cceteris  parihus,  emaciation 
of  the  chest  wall.  One  may  get  pure  hyper- 
resonance  absolutely  on  the  one  side,  the 
healthy,  if  there  is  extensive  dulness,  as  from 
pleuritic  exudation,  on  the  other;  but  there  is 
always  the  possibility  in  such  a  case  of  the 


42        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

student  being  misled  simply  by  the  broad 
contrast. 

(d)  Tymioanitic,  or  dull-tympanitic  note. 
Percussing  over  the  left  infra-mammary  region, 
we  occasionally  get  a  comparatively  high 
degree  of  tympanitic  sound  conveyed  from  the 
stomach.  This  will  be  most  apparent  and 
most  widely  spread  in  cases  of  lung  retraction 
which  admit  of  the  elevation,  or  favour  the 
undue  distension,  of  the  stomach.  It  may  be 
so  high  as  to  stop  abruptly  at  the  line  of 
cardiac  dulness.  But  as  a  pure  pulmonary 
phenomenon  it  is  best  heard  in  a  large  well- 
defined  superficial  cavity. 

Dull-tympcmitic,  though  apparently  a  con- 
tradictory term,  represents  a  sound  that  is 
fairly  easy  to  get  hold  of,  and  it  is  one  that  is 
far  from  being  uncommon.  It  is  heard  over 
cavities  which  are  smaller  and  which  are 
surrounded  by  consolidation.  We  may  get  it 
where  there  is  consolidation  and  no  cavity,  in 
which  case  the  tympanitic  element  must 
come  from  a  larger  underlying  bronchus. 
Theoretically  it  is  what  we  would  expect  from 
a  cavity  tensely  filled  with  air,  which,  other- 


AMPHORIC  RESONANCE.  43 

wise,  would  have  given  the  pure  tympanitic 
note. 

(e)  The  cracked-ioot  sound  {Bruit  de  ^jot 
fele).  Laennec,  who  first  described  this  sound, 
considered  tliat  it  indicated  a  cavity  near  the 
surface  of  the  lung,  and  stated  that  it  was  only 
obtained  in  spare  subjects  whose  ribs  were 
more  than  usually  movable.  This  has  always 
been  accepted  as  the  common  condition  under 
which  it  arises.  But  undoubtedly  it  can  also 
occasionally  be  heard  above  the  level  of  the 
dulness  of  pneumonia  or  of  pleuritic  eflfusion. 
It  is  stated  to  be  heard  sometimes  in  children 
with  bronchitis,  or  in  a  healthy  child  while 
crying  ;  also  in  cases  of  thoracic  fistula,  as  after 
paracentisis  thoracis.  (See  note  p.  35.)  In  the 
adult  it  is  only  heard,  we  may  say,  in  the 
infra-clavicular  and  upper  half  of  the  mammary 
regions.  It  is  best  brought  out  by  firm  per- 
cussion, during  the  act  of  expiration,  and  by 
the  patient  opening  the  mouth. 

(/)  Amphoric  resonance  {amphora,  a  jar). 
As  the  term  implies,  this  is  a  clear  ringing 
note,  like  that  produced  by  striking  an  empty 
cask  or  jar.     It  is  a  musical  ringing  tone  of  a 


44        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

metallic  character,  with  a  resonance  that 
approaches  an  actual  echo,  so  that  it  is  some- 
times called  on  that  account  ''  metallic  echo." 
It  occurs  in  its  most  perfect  form  in  pneumo- 
thorax, but  here  again  the  tension  must  not 
be  excessive.  If  infra-pulmonary  it  can  only 
indicate  a  very  large  cavity,  having  smooth 
unbroken  walls  and  situated  near  the  surface 
of  the  lung.  Like  the  cracked-pot  sound,  it 
requires  a  degree  of  flexibility  of  the  chest 
wall,  and  is,  therefore,  best  heard  when  the 
cavity  is  just  under  the  upper  front  of  the 
chest  and  when  the  parietes  have  become 
considerably  emaciated. 

The  Sense  of  Resistance,  that  is  often 
brought  out  on  percussion,  must  be  referred  to 
in  concluding  this  part  of  our  subject.  It  is  a 
feeling  of  solidity  conveyed  to  the  percusser 
alone,  which  often  gives  him,  insensibly  it 
may  be,  an  advantage  over  those  who  are 
merely  listening.  It  conveys  the  simple  im- 
pression of  there  being  a  more  or  less  dense 
solid  body  under  the  finger,  and  it  coincides 
practically  with  a  corresponding  degree  of 
dull  percussion. 


IMMEDIATE  AUSCULTATION.  45 

AUSCULTATION. 

Of  the  ordinary  methods  of  physical  ex- 
amination we  come  now  to  the  last  in  order 
of  procedure,  the  last  to  be  discovered,  or, 
at  least,  to  be  systematically  described  and 
l)ractised;  the  most  applicable  and  delicate 
of  all,  Auscultation. 

By  this  term  is  understood  practically 
mediate  auscultation,  or  auscultation  through 
the  medium  of  the  stethoscope.  We  always 
speak  of  immediate  auscultation  when  we 
refer  to  the  direct  application  of  the  ear  to 
the  chest.  This  latter  method  in  some  irreo-u- 
lar  form  has  been  practised  from  the  earliest 
days  of  medicine,  while  mediate  auscultation 
dates  only  from  1816,  when  Laennec  first 
listened  to  the  sounds  of  the  heart  with  his 
improvised  stethoscope,  a  roll  of  paper.^ 

Immediate  auscultation  being  now  quite 
exceptionally  practised,  its  consideration  may 
be  dismissed  in  a  few  words  at  the  outset. 
It  is  only  suitable  in  the  examination  of  the 

^  At  the  Clinique  of  Coi-visart,  Laennec  had  previously 
seen  his  fellow-student,  Bayle,  apply  his  ear  directly  to 
the  chest  to  examine  the  heart. 


46        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

back,  and  even  with  that  limitation  is  seldom 
employed,  except  in  the  case  of  children,  or 
in  the  adult  whose  weakness  demands  as 
rapid  an  examination  as  possible.  In  the 
common  bronchitis  of  children  all  that  is 
wanted  by  auscultation  can  be  obtained  by 
applying  the  ear  to  the  back  as  the  child 
lies  on  the  nurse's  lap ;  or,  in  the  case  of  the 
adult,  a  rapid  survey  of  the  back  can  be 
made  in  the  same  way,  as  he  sits  for  a 
second  or  two  supported  in  bed,  a  towel 
being  first  laid  smoothly  on  the  back  for 
the  sake  of  cleanliness.  Sounds  are  heard 
more  loudly  in  this  way,  but  they  are  drawn 
from  a  wdder  area;  a  more  localised,  more 
circumscribed  range  of  sound  is  caught  up 
by  the  stethoscope. 

Mediate  auscultation,  or  simply  ausculta- 
tion, implies  the  use  of  a  stethoscope.  We 
need  not  discuss  the  merits  of  the  various 
kinds.  We  believe,  as  we  were  taught,  that 
the  best  of  all  is  one  of  light  wood  in  one 
piece,  with  an  ear  plate  that  will  best  adapt 
itself  to  the  particular  ear,  and  a  chest  bell 
IJ  inch  in  diameter,  with  a  little  breadth  of 


THE  STETHOSCOPE.  4/ 

margin  that  will  lie  flatly  on  the  chest  wall 
where  that  is  possible.  Many  prefer  one  of 
light  metal.  It  conveys  sound  better,  cer- 
tainly, than  vulcanite,  and  may  in  some  cir- 
cumstances do  so  better  than  one  of  wood. 
Stethoscopes  that  can  be  disjointed  are  more 
portable,  but  are  not  to  be  recommended  on 
other  grounds.  Those  made  of  materials  of 
different  density  are  very  objectionable. 

The  flexible  binaural  stethoscope  need 
hardly  be  described  as  it  is  a  familiar  enough 
object  in  the  wards.  It  has  no  advantages 
that  for  a  moment  counterbalance  the  great 
disadvantage  of  training  one's  self  to  the 
employment  of  two  such  different  methods 
of  mediate  auscultation;  for  surely  few  will 
hold  that  the  exclusive  use  of  the  binaural 
is  to  be  preferred  to  that  of  the  simple  ordi- 
nary form.  The  differential  stethoscope  is  a 
binaural  in  which  the  tube  of  each  earpiece 
is  continued  into  a  separate  chestpiece.  It 
may  be  convenient  in  some  cases  where  we 
wish  to  compare  rapidly  two  different  parts 
of  the  chest. 

In  using  the  stethoscope  there  are  one  or 


48         ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

two  obvious  precautions  that  must  be  re- 
membered. Possibly  it  is  because  they  are 
so  common-place  that  they  are  so  habitually 
overlooked  by  beginners.  Never  press  heavily 
with  the  stethoscope.  It  is  a  common  occur- 
rence for  the  tyro  to  cause  the  patient  pain 
in  this  way ;  it  is  never  done  by  the  expert. 
Be  careful  always  to  adapt  the  bell  of  the 
stethoscope  fairly  to  the  chest.  Carry  the 
ear  to  the  earpiece  without  moving  the 
stethoscope  in  the  least  from  its  position.  I 
would  not  mention  such  a  thing  were  it  not 
in  my  experience  an  every  day  occurrence 
with  beofinners.  There  is  not  a  sound  but 
what  is  thereby  modified ;  and  should  it  ac- 
cidentall}^  occur,  the  vibration  of  the  air  itself 
in  the  stethoscope  is  at  once  recognised  by 
the  practised  ear,  warning  him  that  some  in- 
equality of  the  chest  surface,  we  shall  sup- 
pose, is  displacing  the  bell  of  the  stethoscope. 
The  auscultator  should  never  put  himself 
into  an  awkward  position  by  bending  so  far 
over  the  patient  as  to  listen,  for  examyjle, 
round  into  the  opposite  lateral  region.  He 
may  in  this   way,  apparently  from   the  rush 


BREATH  SOUNDS.  49 

of  blood  to  the  head,  quite  fail  to  hear  an 
otherwise  fairly  audible  sound.  Obviously, 
too,  nothing  should  touch  the  stethoscope  or 
rub  against  the  patient's  chest,  or  then  the 
most  startling  friction  sounds  may  be  heard. 
Hair  on  the  chest  may  produce  fine  crack- 
ling sounds  from  contact  with  the  stethoscope. 
The  simplest  and  most  efiectual  plan  to  obviate 
this  which  I  have  seen  practised,  is  to  lay 
on  the  skin  a  small  piece  of  wet  blotting 
paper  sufficiently  large  for  the  bell  of  the 
stethoscope. 

AUSCULTATIOX  IX   HEALTH. 

As  with  the  other  methods  of  examina- 
tion we  have  to  study  first  the  normal 
phenomena  disclosed  by  auscultation.  These 
are  (1)  the  breath  sounds,  and  (2)  the  voice 
sounds. 

1.  Breath  Sounds. — By  that  we  understand 
the  sounds  caused  by  the  ingress  and  the 
ecjress  of  air  alono-  the  whole  course  of  the 
respiratory  tract.  That  tract  may  be  con- 
veniently divided  into  three  parts,  furnishing 

us    with    three    different    classes    of    sound 

D 


50        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

known  as  tracheal,  bronchial,  and  vesicular. 
We  shall  see  by  and  by  that  the  first 
is  not  studied  for  its  own  sake,  but  on 
account  of  what  it  may  illustrate  as  a  stan- 
dai'd  for  comparison.  Each  of  these  three 
parts,  then,  has  its  own  respiratory  murmur; 
bub  when  the  "respiratory  murmur"  simply, 
or  the  "  R.M.,"  is  spoken  of,  the  vesicular  is 
usually  understood. 

The  Tracheal  Sound. — The  student  should 
leave  description  now  and  listen  carefully 
for  himself  in  a  friend  or  patient.  Let  him 
then  tr}^  to  describe  the  sound.  He  will 
find  it  no  easy  matter,  and  the  more  familiar 
he  becomes  with  it  he  will  find  that  its  ade- 
quate description  becomes  all  the  more  difii- 
cult.  He  will  learn  that  a  description  can 
onl}''  suggest.  At  the  same  time,  after  com- 
paring it  with  the  other  respiratory  sounds, 
he  will  probably  understand  that  the  tracheal 
sound  is  loud,  harsh,  hollow,  very  distinct, 
or  a  better  word,  articulate,  with  an  evident 
interval  between  inspiration  and  expiration, 
the  latter  sound  being  rather  the  louder  of 
the  two. 


THE  VESICULAR  SOUND.  51 

The  BTonchial  Sound. — Here,  again,  it  is 
best  for  the  student  simply  to  listen  for  him- 
self in  one  or  other  inter-scapular  region  close 
to  the  vertebral  column,  between  the  level  of 
the  seventh  cervical  and  the  third  or  fourth 
dorsal  vertebrae.  He  will  observe  that  its 
character  is  less  harsh,  less  articulate  than 
the  tracheal  sound,  but  still  distinctly  hollow. 

The  Vesicular  Sound,  the  Respiratory 
Murmur,  or  R.M. — What  we  have  said  of 
the  study  of  the  two  foregoiu'g  sounds  applies 
most  of  all  to  this  one.  The  only  way  to 
know  it  is  to  listen  to  it  habitually.  It  can- 
not be  imitated,  for  any  imitation  we  attempt 
has  qualities,  which  are,  compared  with  the 
sound  itself,  far  too  positive.  It  is  simply  air 
in  motion.  We  know,  indeed,  that  it  is  not 
really  free,  but  there  is  always  the  sense  of 
freedom.  We  may  call  it  extremely  soft  and 
homogeneous,  but  it  is  best  described  nega- 
tively. It  is  not  rough,  not  harsh,  not  hollow, 
not  confined.  Then  the  inspiration  and  ex- 
piration must  be  separately  studied  and  com- 
pared. The  latter  is  fainter  and  shorter 
than   the   former,  being   variously  stated   at 


52         ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

one  third,  one  fourth,  or  only  one  sixth  of 
the  former.  Indeed,  Hyde  Salter  held  that 
in  the  tranquil  unconscious  respiration  of 
health  there  is  no  audible  expiration  sound 
at  all,  and  Walshe  thinks  it  is  absent  in 
one  case  out  of  four.  The  expiration  sound 
is  lower  in  pitch  also. 

The  R.M.  varies  considerably  within  normal 
limits.  It  may  hardly  be  heard  at  all ;  or 
again  it  may  be  that  its  intensity  leads  to  the 
suspicion  of  incipient  pulmonary  mischief. 
The  absence  of  any  other  evidence  of  disease 
and  the  equal  character  of  the  respiration 
itself  over  corresponding  areas  of  each  side 
will  determine  our  opinion  of  its  healthy 
character.  Practically  this  equality  must  be 
held  to  be  characteristic  of  healthy  breathing. 
It  is  more  distinct  in  the  infra-clavicular 
regions  and  under  the  scapulae  posteriorly 
than  elsewhere;  or,  as  Walshe  succinctly  puts 
it,  "The  sounds  are  fuller  superiorly  than 
inferiorly  and  in  front  than  behind."  The 
student  will  not  fail  to  notice  how  markedly 
emaciation  of  the  chest  walls  intensifies  all 
intra-thoracic  sounds.     In  the  rarer  unilateral 


ORIGIN  OF  INSPIRATORY  MURMUR.  53 

atrophy  of  one  or  other  muscle  or  set  of 
muscles  (for  example,  in  ^progressive  muscular 
atrophy)  this  has  been  strikingly  demon- 
strated. On  the  other  hand,  the  R.M.  is 
diminished  b}^  a  superabundance  of  sub- 
cutaneous tissue.  "  Fat  and  muscle,"  as 
Latham  says,  "damp  the  sound,  where  they 
abound  above  measure,  as  effectually  as  coats 
and  waistcoats." 

Origin  of  the  Respiratory  Murmur. — On  applying  the 
stethoscope  to  the  chest  "we  hear,"  says  Laennec, 
"  during  inspiration  and  expiration,  a  slight  but  extremely 
distinct  murmur,  answering  to  the  entrance  of  the  air  into, 
and  its  expulsion  from,  the  air  cells  of  the  lungs. "  One 
almost  regrets  that  this  sunple  statement  of  the  origin  of 
the  E.M.  was  ever  disputed.  It  remained  virtually 
uncontradicted  till  18.34,  when  M.  Beau  vigorously 
defended  the  view,  previously  suggested  by  Chomel,  that 
it  was  really  the  sound  of  the  air  passing  through  the 
narrow  glottis  which  was  heard  by  being  conducted  along 
the  bronchi.  Since  then,  the  question  has  afforded  an  ample 
basis  for  speculation  and  experiment,  with  a  balance  of 
opinion  rather  in  fa^'our  of  Laennec's  view.  Dr.  Joseph 
Coats  had  recently  an  exceptional  opportunity  of  investi- 
gating the  matter  in  a  case  in  which  Dr.  Xewman  had 
successfully  performed  excision  of  the  larynx  for  maUgnant 
disease.  We  need  only  give  the  finding  of  the  committee 
appointed  to  co-operate  with  Dr.  Coats,  consisting  of  Prof. 
Gairdner,  Drs.  Kewman  and  Lindsay  Steven,  which  was  to 
the  effect  "that  it  must  be  considered  to  be  perfectly  well 
established  that  the  presence  or  absence  of  a  glottis  or  of 


54        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

any  corresponding  arrangement  ....  at  the  anatomical 
site  of  the  larynx  has  no  influence  whatever  in  the  produc- 
tion of  the  normal  vesicular  murmur." — Glas.  Med.  Jr. 
ii.,  1886,  p.  384. 

Auscultation  in  Disease. 

We  have  seen  that  the  respiratory  murmur 
differs  in  character  and  degree  at  different 
parts  of  the  respiratory  tract,  and  also  that  the 
vesicular  respiratory  murmur  as  heard  over 
the  chest  generally,  differs  somewhat  in 
different  people.  We  have  now  to  consider 
ahnoTT)%al  alterations  in  the  strictly  vesicular 
R.M. 

Alterations  in  Degree. — (a)  The  E.M.  may 
be  simply  diminished.  Little  air  may  be  reach- 
ing that  part  of  the  lung.  Of  this  there  are  a 
great  number  of  possible  causes,  such  as  spas- 
modic stricture,  as  in  asthma;  inflammatory 
thickening,  as  in  bronchitis;  the  pressure  or 
the  mere  presence  of  an  aneurism  or  other 
tumour.  There  may  be  little  air  current,  as 
in  emphysema,  or  in  the  restricted  thoracic 
movement  of  painful  pleurisy.  The  lung 
capacity  may  be  invaded,  as  in  partial  collapse 
or  consolidation. 


EXAGGERATED  riESPIRATIOX  SOUND.  55 

(h)  The  R.M.  may  be  completely  suppressed. 
Any  of  the  conditions  just  mentioned  if  aggi*a- 
vated  will  cause  complete  suppression  over  a 
greater  or  smaller  area.  Fluid  or  air  in  the  pleu- 
ral cavity,  or  false  membrane  over  the  pleural 
surface,  will  cause  diminution  or  suppression 
of  the  R.M.  by  affecting  the  transmission  of 
the  breath  sounds  to  the  ear,  or  to  some 
extent  also,  by  modifying  their  production. 

(c)  The  R.M.  may  be  exaggerated.  By  this 
must  be  clearly  understood  simple  loudness:  not 
a  change  in  character  but  in  degree.  It  means 
that  this  part  of  the  lung  is  doing  extra  work 
on  account  of  other  parts,  or  the  other  lung, 
being  incapacitated.  It  is  usually  well  marked 
when  there  is  collapse,  or  consolidation,  or 
considerable  destruction,  of  other  parts  of  the 
respiratory  area.  It  is  generally  termed 
supplementary  respiration.  It  is  exactly  like 
the  natural  breath  sound  in  children,  as 
Laennec  pointed  out,  giving  it  on  that  account 
the  name  of  "  puerile  respiration."  We  must 
remember  then,  more  especially  in  view  of 
what  we  are  going  to  consider  next,  that  by 
puerile  or  supplementary  breathing  we  mean 


56        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

simply  respiration  of  increased  intensit}^.  Not 
that  puerile  breathing  in  the  adult  is  always 
supplementary,  but  supplementary  breathing 
is  always  puerile. 

Wavy,  Jerky,  or  Gog-wheel  Resjnration. 
— We  have  just  been  speaking  of  alterations 
in  degree.  We  have  now  to  consider  abnor- 
mal alterations  in  character.  To  do  this 
properly  we  must  go  back  and  start  anew 
from  the  normal  state.  We  notice  not  unfre- 
quently  in  healthy  people,  particularly  if  they 
breathe  slowly,  that  the  H.M.  is  not  quite 
uniform.  It  could  not  be  called  broken ;  one 
would  rather  say  it  is  bending.  As  a  matter 
of  fact  it  is  termed  wavy}  It  is  quite  recog- 
nised to  be  a  normal  phenomenon.  But 
whenever  we  can  say  that  the  sound  is 
actually  interrupted,  what  would  be,  and  is 
called,  jerky ;  or  still  more,  is  so  sharply  and 
completely  broken  as  to  be  sometimes  termed 
cog-wheel,  then  we  know  that  we  have  before 
us  an  almost  positive  sign    of  a  form  of  in- 

^The  term  wavy  respiration  was  first  used  by  Dr. 
Theophilus  Thomson  in  his  Clinical  Lectures  on  Pulmonary 
Consumption  (1854). 


INTERRUPTED  RESPIRATION  SOUND.  57 

cipient  disease.  For  it  usually  indicates  early 
phthisis,  particularly  when  heard,  as  it  gener- 
ally is,  in  one  or  other  apex.  It  is  believed  to 
be  due  to  infiltration  of  the  air  cells  and  re- 
duction of  the  calibre  of  the  minute  bronchi 
from  tumefaction  of  their  mucous  membrane. 
In  a  kind  of  diagrammatic  way  for  purposes 
of  study,  it  may  be  conveniently  viewed  as 
the  first  indication  of  a  departure  from  health. 

When  heard  under  normal  conditions  in  the  neighbour- 
hood of  the  heart  this  wavy  breath  sound  seems  to  be  due 
to  the  cardiac  impulse.  If  it  can  be  made  out  to  be  syn- 
chronous with  the  cardiac  systole,  it  is  sometimes  called 
the  systolic-vesicular  murmur.  But  it  is  frequently  heard 
over  the  right  lung  and  in  parts  generally  remote  from  the 
heart.  In  such  circumstances  it  is  found  to  be  impossible 
to  determine  its  relation  to  the  heart's  action  ;  yet  it  is 
reasonable  to  suppose  that,  in  many  cases  at  least,  it  is 
due  to  the  pulmonic  capillary  circulation,  just  as  we  see 
the  ball  of  the  thumb,  or  the  foot  of  the  leg  which  is 
resting  on  the  other  knee,  moved  by  the  systemic  impulse. 
Roger  and  Barth  believe  that  this  "  respiration  saccad^e," 
as  it  is  termed  by  the  French,  is  brought  about  in  various 
ways — (1)  Sometimes  by  an  irregular  or  jerky  movement 
of  the  thoracic  walls  ;  (2)  Again,  but  more  obscurely  by 
an  incomplete  or  tardy  expansion  of  certain  areas  of  the 
lung  ;  (3)  By  the  cardiac  impulse  as  above  noted,  if  heard 
in  the  left  infra-clavicular  region ;  and  (4)  A  temporary 
irregularity  in  breathing  induced  by  the  mere  stethoscopic 
examination. 


58        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

Prolonged  Expiration  Sound. — This  must 
be  distinguished  from  prolonged  expiration, 
which  has  reference  to  the  whole  act,  and 
is,  for  example,  a  feature  of  Asthma.  We 
are  only  now  speaking  of  prolonged  expira- 
tion sound.  There  is  no  reference  to  it  by 
Laennec;  and  to  Dr.  Jackson,  of  Boston,  is 
due  the  credit  of  its  discovery  in  1833.  He 
recognised  its  ordinary  significance,  namely, 
early  tubercular  infiltration ;  and  explained 
it  by  supposing  that  as  the  vesicular  R.M. 
became  thereby  less  and  less  possible,  the 
bronchial  element,  itself  unaltered,  came  as 
it  were  more  and  more  to  the  front.  But 
there  are  obvious  difficulties  in  accepting  this 
or  any  one  explanation  of  a  phenomenon  occur- 
ring under  such  complex  conditions.  One  can 
hardly  believe  it  possible  that  so  early  a 
symptom  of  pulmonary  phthisis  can  be  due  to 
such  a  degree  of  consolidation  as  we  must 
suppose  is  necessary  to  materially  increase  the 
conducting  power  of  the  lung.  But  vesicular 
emphysema  is  also  a  great  cause  of  prolonged 
expiration  sound,  and  this  has  led  to  the  sup- 
position  that    diminished    elasticity    of    the 


HARSn  RESPIRATION.  59 

alveolar  walls  is  the  explanation.  Certainly 
in  the  latter  malady  it  is  a  purer  prolongation ; 
in  the  former  there  is  a  change  in  qualit}^ 
an  approach  to  harshness  also,  which  may  be 
due,  as  has  been  supposed,  to  the  tubercular 
deposition  encroaching  on  the  lumen  of  the 
minute  bronchi. 

Harsh  Respiration. — There  can  be  no  doubt 
that  this  is  entitled  to  separate  consideration. 
It  is  more  than  puerile  respiration,  which  is 
simply  loud  or  strong.  Harsh  respiration  con- 
cerns the  expiratory,  as  well  as,  or  even  more 
than,  the  inspiratory  act ;  and  although  Bron- 
chial, and  still  more  Tracheal,  Respiration  is 
harsh,  harsh  respiration  'per  se  is  not  hollow 
at  all.  As  to  its  character,  there  is  the  well- 
known  figure  which  compares  the  normal  R.M. 
to  the  summer  breeze  playing  in  the  leaf}' 
grove,  and  harsh  respiration  to  the  winter's 
blast  coursing  through  the  leafless  tree  tops. 
This  may  possibl}^  conve}^  to  the  student  the 
kind  of  thing  he  has  to  expect,  but  the  sound 
itself,  like  all  the  other  sounds,  must  be  really 
heard  and  studied  to  be  really  known. 

As  a  siofn  of  tubercular  infiltration,  harsh 


60        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

R.M.  may  be  considered  to  be  an  advance 
upon  prolonged  expiration.  It  points  more 
particularly  to  that  bronchial  catarrh  which 
is  often  the  accompaniment  of  tubercle ;  it 
possibly  arises  sometimes  from  diminished 
secretion,  sometimes  from  inflammatory  thick- 
ening. 

Bronchial  Respiration. — By  this  we  do  not 
mean  bronchial  respiration  where  it  exists 
naturally,  for  to  this  we  have  already  referred, 
but  bronchial  breathing  where  we  would  ex- 
pect vesicular  breathing.  It  is  harsh,  but  it  is 
hollow  as  well.  Harsh  E-.M.  is  more  marked 
with  expiration  as  a  rule;  in  bronchial  R.M., 
inspiration  also  is  harder,  drier,  and  rougher. 
But  it  needs  little  description,  as  it  can  be 
studied  at  its  own  normal  situation  in  health. 

It  signifies  either  pulmonary  infiltration  or 
condensation.  The  former  may  be  either  tuber- 
cular or  pneumonic;  the  latter  (the  conden- 
sation) is  occasioned  most  commonly  by  the 
pressure  of  pleuritic  effusion.  Cancerous  and 
other  tumours  are  occasional  causes  of  bron- 
chial respiration,  and  may  act  in  either  of  the 
ways  just  mentioned.     The  physical  condition 


TUBULAR  RESPIRATION.  G  1 

common  to  both  is  a  medium  more  uniform 
than  the  normal  lung  tissue  with  its  con- 
tained air,  and  in  this  way  the  sound  from  the 
neighbouring  unaffected  bronchi  is  unduly 
carried  to  the  chest  surface  and  to  the  ear. 

Tubular  Respiration. — I  venture  to  hold 
strongly  with  those  who  give  to  the  term 
'tubular  breathino''  a  meanino-  distinct  from 

o  o 

'  bronchial  breathing.'  Unquestionably,  one 
frequently  hears  in  pneumonic  consolidation  a 
kind  of  breath  sound  that  is  never  heard  in 
normal  bronchial  respiration.  It  is  more 
metallic  or  brassy;  more  like  the  sound  of 
blowino;  throuo'h  a  brass  or  tin  tube.  Or 
better  still,  it  gives  to  the  listener  the  impres- 
sion, as  has  been  often  said,  of  air  beino; 
drawn  from,  and  puffed  back  to,  the  ear  in 
inspiration  and  expiration  respectively.^ 
The  phenomena,  as  Walshe  says,  appear  to 
occur  in  a  space  limited  to  the  immediate 
neighbourhood  of  the  part  examined.  Bron- 
chial K.M.  again  is  practically  his  "diffused 
blowing  respiration." 

^  It   was  first  described   by   Laennec,    who   termed    it 
^Respiration  soufflante"  blowing  or  puffy  respiration. 


62        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

Cavernous  Jtespiration. — No  description  of 
this  is  needed  ;  the  term  explains  itself.  The 
sound  at  once  suggests  a  cavity.  It  is  un- 
mistakably hollow.  There  is  more  volume  in 
the  tone,  and  the  pitch  is  lower,  especially  of 
expiration,  than  in  any  of  the  preceding 
groups.  For  its  production  it  requires  a  cavity 
of  considerable  size  near  the  lung  surface  or 
with  surrounding  condensation,  containing 
little  or  no  fluid,  and  communicating  with 
one  or  more  bronchi.  In  the  great  majority 
of  cases  it  will  be  near  the  lung  surface,  and 
of  tubercular  origin.  But  it  ma}^  proceed  from 
a  somewhat  globular  or  ampullar  dilatation  of 
a  bronchus ;  or  still  more  rarely,  the  cavity 
may  result  from  gangrene  or  abscess. 

A'lnphoric  Respiration. — This  is  the  highest 
degree  of  pure  hollow  sound.  Again  the  name 
explains  its  character;  it  is  like  the  sound 
produced  by  blowing  over  the  mouth  of  an 
amphora  or  jar.  We  are  reminded  of  a  deep 
musical  tone  with  its  pure,  well-marked 
resonance,  amounting  almost  to  a  true  echo. 
It  has  also  frequently  a  kind  of  metallic  ring, 
and  is  always  a  highl}^  articulate  (close-to-the- 


RALES.  63 

ear)  sound.  It  can  only  be  produced  in  a  very 
large  cavity,  larger  than  one  would  readily  ex- 
pect to  find  in  the  lung  tissue.  Still  it  may 
be  caused  by  an  intra-pulmonary  cavity,  but 
it  is  said  it  must  be  of  the  size  of  the  closed 
fist.  Certainly  all  the  conditions  that  lead  to 
the  cavernous  breath  sound  must  be  here  in 
the  highest  perfection. 

A  much  more  frequent  cause  of  the  typical 
amphoric  sound  \s>  pneiiino-tliorax.  An  air  con- 
taining cavity  is  always,  of  course,  an  essential. 
In  the  great  majority  of  such  cases,  the  air 
has  been  admitted  by  a  fistulous  opening,  most 
commonly  in  the  visceral  pleura,  the  result  of 
tubercular  ulceration. 

BALES. 

Hitherto  we  have  been  dealing  with  modifi- 
cations of  the  E..M.  We  have  now  to  consider 
wbat  are  practically  additions  to  it ;  what  are 
truly  adventitious  sounds.  The  word  "rale'' 
was  adopted  by  Laennec,  it  being  the  term 
commonly  applied  to  the  sound  in  the  throat 
of  the  dying :  the  death-rattle,  le  rale  de  la 
mort.   He  gave  to  the  word  the  wider  significa  • 


64        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

tion  which  it  has  ever  since  borne,  and  which 
includes  all  abnormal  sounds  produced  within 
the  respiratory  tract,  whether  by  the  presence 
of  fluid  secretion  there  in  excess  along  with 
air  in  motion,  or  by  the  narrowing  or  roughen- 
ing of  the  air  passages  themselves. 

Rales  may  be  heard  with  inspiration  or 
expiration ;  with  either  alone,  or  with  both. 
When  we  hear  a  rale,  we  form  an  opinion,  of 
course,  on  its  general  character;  such  as  its 
amount  and  loudness;  but  in  particular  we 
judge  (1)  Whether  it  is  dry  or  moist,  and  (2) 
Whether  it  is  coarse  or  fine. 

The  student  will  defer  with  advantage  the  study  of  the 
unnumbered  classifications  of  rales,  nor  need  he  pursue,  to 
the  bitter  end,  the  vexed  question  of  what  is  to  be  held  as 
a  dry,  and  what  as  a  moist,  rale.  Much  difference  of 
opinion  is  due  apparently  to  the  fact  that  some,  very 
properly  I  think,  consider  only  the  sound  itself,  while 
others  think  of  the  cause  of  the  sound.  (See  further 
under  Cr&pitant  Rale. ) 

The  following  classification  of  rales,  practi- 
cally that  taught  by  Gairdner,  seems  to  be 
very  generally  accepted.  None  could  be  at 
once  more  simple  and  more  comprehensive. 
It  includes — (A)  The  Sonorous  or  Sibilant 
Belle;    (b)  The  Mucous   or   Bubbling   Bale; 


OKGAN-PIPE  KALES.  65 

(c)    The   CveintaTit  Rale;  and  (d)  Mixed   oi- 
Indetei^iinate  Rales.     Also  Friction  Rale. 

(a)  The  Sonorous  or  SihiloMt  (snorinf/ 
or  whistlincj)  Rale. — This  class  includes  low- 
toned  snoring  sounds  up  to  those  highest  in 
the  musical  scale  which  become  simply  a 
whistle.  They  were  classed  separately  by 
Laennec,  but  they  differ  only  in  pitch.  It  is 
always  a  dry  rale,  and  always  evidently  so. 
It  is  the  familiar  cooing  rale,  and  has  always 
something  of  a  musical  qualit}^.  It  may  be 
heard  both  with  inspiration  and  expiration. 
Gairdner,  having  regard  both  to  their  quality 
and  mode  of  production,  styles  them  "  Organ- 
pipe  Rales."  The  term  suggests  to  us,  what  is 
undoubtedly  the  general  rule,  that  the  larger 
bronchi,  like  the  larger  organ-pipes,  produce 
the  lower  tones,  while  the  smaller  bronchi  can 
only  form  the  higher  tones. 

These  rales  are  so  constantly  associated 
with  bronchitis,  bronchial  catarrh,  and  asthma, 
that  we  may  assume  they  are  caused  by  a 
swollen  mucous  membrane,  a  piece  of  oc- 
cluding   mucus    or   pus,    or   a    spasmodically 

constricted    bronchus,    forming    a   fissure   or 

E 


66        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

chink  whose  vibrating  surface  or  edges  occa- 
sion a  musical  tone.  There  is  no  necessity 
for  supposing,  as  some  do,  that  these  rales 
are  only,  or  even  commonly,  found  at  the 
bifurcation  of  a  bronchus.  They  are  easily 
coughed  away  if  they  arise  from  ordinary 
bronchial  catarrh ;  even  a  deep  breath  may 
destroy  them.  Those  of  asthmatic  origin  will 
persist  till  the  spasm  disappears.^ 

(b)  The  ■  Mucous  or  Bubbling  Bale. — The 
rales  of  this  class  are  .as  evidently  moist  as 
the  foregoing  are  dry.  They  consist  of  a 
series  of  explosions  of  air  through  liquid. 
We  speak  of  them  as  being  large  or  small, 
or  as  coarse  and  fine.  The  smaller  would 
be  termed  generally  mucous;  the  larger, 
those  that  can  be  separately  heard,  probably 
rather  bubbling.  They  are  likely  to  be  larger 
in  the  larger  bronchi  or  in  a  cavity,  but  by  no 
means  necessarily  so.  Obviously  the  larger 
the   bronchi    in    which   they   are,   the   more 

^  Some  restrict  the  word  Rhonchus  to  mean,  not  a  rale 
generally,  but  this  dry  snoring  rale.  This  has  the  merit 
of  being  etymologically  more  correct,  but  the  word  is  not 
needed. 


THE  CEEPITANT  HALE.  67 

readily  will  they  be  modified  or  destroyed  by 

The  clicking  rale  is  of  the  same  class. 
Here  the  fluid  is  simply  thin,  and  so,  as  a 
consequence,  are  the  walls  of  the  air-bells. 
They  therefore  break  with  that  sharper  sound 
which  the  name  indicates.  It  is,  as  a  rule, 
but  not  constantl}?",  a  fine  rale. 

These  rales  always  signify  the  presence  of 
fluid  in  the  air-passages.  They  constitute 
the  ordinary  sign  of  bronchitis  in  which 
there  is  a  free  secretion.  They  will  probably 
be  most  abundant  at  the  back,  and  towards 
the  base  of  both  lungs.  So  also  in  pulmonary 
oedema,  congestion,  etc. 

Again,  they  are  heard  in  tubercular  soften- 
ing, more  particularly  if  that  is  rapidly  ad- 
vancing. In  this  case  they  are  most  likely  to 
be  about  the  apex  of  one  lung,  or  at  least 
most  marked  there.  The  clicking  is  more 
commonly  the  sign  of  the  catarrh  of  tubercle. 
Fine  moist  rales  lingering  about  an  apex 
should  never  be  overlooked. 

(c)  The  Crepitmit  Rale. — The  true  crepitant 
rale   has  a  very  fixed   character   and   is   the 


68        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

finest  of  all  rales.  It  is  typical  of  the  first 
stage  of  lobar  pneumonia ;  it  is  heard  only 
with  inspiration,  and  particularly  towards  the 
close  of  that  act.  It  consists  of  a  succession 
of  minute  rapidly  evolved  crackles,  variable 
in  number,  but  all  perfectly  similar  in  char- 
acter. It  was  likened  by  the  older  Williams 
to  the  sound  produced  by  rubbing  the  hair 
over  the  ear,  and  no  better  comparison  has 
ever  been  made.  Forced  breathing,  cough,  or 
expectoration,  have  absolutely  no  influence 
upon  it.  It  persists  till  pneumonic  consoli- 
dation is  complete,  that  is,  until  air  can  no 
longer  enter  the  alveoli. 

The  rale  is  probably  caused  by  the  air- 
current  separating  the  over  moist  and  per- 
haps slightly  adhering  walls  of  the  pulmon- 
ary parenchyma;  but  whether  of  the  alveoli, 
or  of  them  and  the  ultimate  bronchi  in  ad- 
dition, it  is  impossible  to  say. 

The  junior  student  should  thoroughly  familiarise  him- 
self with  the  above  account  of  the  crepitant  rS,le  before 
he  proceeds  to  the  study  of  exceptions.  Some  affirm  that 
this  rale  may  occasionally  be  heard  with  expiration  also. 
So  very  rare  must  this  be  that  probably  the  statement  has 
"  originated  in  the  confusion  which  long  prevailed  between 


MIXED  RALES.  69 

the  crepitant  rale  of  pneumonia  and  tlie  small  bubbling 
rale  of  capillary  bronchitis  "  (Walshe).  Very  possibly  the 
alleged  occurrence  in  rare  instances  of  this  rMe  in  pulmon- 
ary a'dema  is  to  be  explained  in  the  same  way.  At  the 
same  time,  whatever  be  the  explanation,  it  is  not  unfre- 
quently  heard  in  the  aged  or  the  very  weak  who  have 
been  for  some  time  confined  to  bed ;  but  in  that  case  it 
can  be  made  to  disappear  by  taking  one  or  two  deep 
inspirations. 

The  true  crepitant  r:\le,  considered  as  a  sound,  should 
surely,  we  think,  be  called  dry.  Is  the  sound  produced 
by  rubbing  the  hair  over  the  ear  not  a  dry  sound  ?  No 
doubt  if  we  believe  that  the  crepitant  rale  is  caused  by 
the  separation  of  the  viscid  walls  of  the  bronchioles  and 
alveoli,  and  think  of  that,  we  may  be  led  to  call  it  moist. 
But  we  positively  lose  something  by  this  interpretation,  as 
we  shall  see  immediately. 

(d)  Mixed  or  Indeterminate  Bales. — When  a 
mucous  rale  is  very  fine,  it  has  probably  also 
lost  much  of  its  liquid  character,  and  alto- 
gether it  frequently  becomes  very  difficult  to 
say  whether  it  is  a  mucous  or  a  crepitant 
sound.  To  such  a  rale  the  name  "  sub-crepi- 
tant"  (somewhat  crepitant)  has  been  pretty 
generally  applied,  or  the  term  "  muco-creyi- 
tantj"  which  indicates  its  hybrid  character. 

The  student  will  understand  now  how  greatly  the  force 
of  this  compound  term,  "  muco-crepitant,"  is  lost  if  we 
cannot  consider  the  mucous  rale  to  be  moist  and  the  crepi- 
tant rale  to  be  dry.     By  muco-crepitaut  we  just  mean 


70        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

that  we  cannot  say  wlietlier  the  rale  is  moist  or  dry.  We 
therefore  only  add  to  the  confusion  already  existing  if  the 
one  part  of  the  word  is  not  fitted  to  express  the  idea  of  the 
one  quality,  while  the  other  part  denotes  the  suspicion 
which  we  have  that  there  is  something  of  the  opposite 
character  as  well. 

The  Crackling  Rale,  which  constitutes 
according  to  Walshe  a  special  class,  calls  for 
no  particular  reference.  Its  name  adequately 
describes  its  character.  It  may  be  viewed  as 
the  dry  rale  which  corresponds  to  the  moist 
clicking  rale.  Nor  do  cavernous,  amphoric, 
etc.,  rales  need  separate  study.  Just  as  these 
terms  represent,  as  we  have  already  seen, 
various  qualities  of  the  R.M.,  so  do  they 
indicate  mere  varieties  of  rale.  We  can 
understand  a  mucous  rale  with  a  cavernous 
quality  having  even  a  quasi-special  character, 
and  being  styled  a  gurgling  rale;  and  a 
clicking  rale  with  an  amphoric  quality  becom- 
ing a  metallic  rale. 

The  metallic  sounds  are  separately  classed  by  some 
writers.  Certainly  in  their  most  typical  form  they  consti- 
tute a  very  striking  and  exceptional  variety.  We  have 
incidentally  referred  to  them  already  but  would  here 
specially  take  note  of  two — metallic  tinlding  and  metallic  hell 
sound.  Pure  metallic  tinkling  was  compared  by  Laennec 
to  the  sound  caused  by  letting  fall  a  pin  or  a  grain  of  sand 


FRICTION  SOUND.  71 

iuto  a  metal  or  glass  cup,  and  as  a  morbid  phenomenon 
has  been  supposed  to  be  caused  by  drops  falling  from  tiio 
roof  of  an  air-filled  cavity  (pulmonary,  or  in  pneumo- 
thorax) into  the  fluid  below.  It  is  very  doubtful  if  this 
tinkling  is  ever  exactly  so  caused.  It  probably  arises 
rather  from  the  bursting  of  large  bubbles  in  large  air-filled 
cavities. 

The  metallic  bell  sound  is  a  term  applied  to  the  clear 
ringing  metallic  sound  which  is  heard  if  one  auscultates 
over  a  pneumo-thorax  while  an  assistant  strikes  a  coin 
placed  on  the  chest  wall  with  another  of  a  similar  kind. 
The  resulting  sound  heard  is  sometimes,  as  Gee  says,  not 
much  infei'ior  to  the  clihne  of  a  small  clock. 

The  sounds  which  have  just  been  under 
discussion,  known  technically  as  rales,  are  al], 
it  will  be  noticed,  intra-pulmonary.  We  pass 
now  to  one  that  is  extra-pulmonary,  which  is 
connected  with  the  pleura  and  is  not  usually 
termed  a  rale  but  simply  a  sound : — 

Friction  Sound  (Friction  Rale — Gairdner). 
In  health  there  is  absolutely  no  sound  caused 
by  the  play  of  the  two  pleural  surfaces  on  each 
other.  The  movement  is  perfectly  free.  But 
let  either  surface  lose  its  perfect  softness  and 
polish,  and  friction  sound,  "  the  pleuritic  rub  " 
as  it  has  been  called,  becomes  possible.  In  its 
ordinary  form  it  can  hardly  be  mistaken. 
What  it  really  is,  the  sound  of  one  roughened 


72        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

surface  rubbing  over  another,  is  self-evident  to 
the  ear  that  can  catch  the  sound  at  all.  It 
conveys,  as  Fagge  says,  "the  impression  of 
something  catching  or  dragging  against  an 
obstruction  and  then  slipping,  but  only  to 
catch  or  drag  once  more."  It  may  be  heard 
either  with  inspiration  or  expiration  or  with 
both.  It  may  be  heard  only  towards  the  end 
of  either,  and,  what  seems  to  have  attracted 
little  notice,  may  sometimes  be  distinctly 
heard  after  the  act  of  expiration,  so  far  as 
thoracic  movement  is  concerned,  is  complete ; 
as  if  the  surface  had  caught  at  the  end  of 
expiration  and  then,  being  elastic,  had  re- 
covered itself. 

If  the  roughness  is  considerable,  the  patient 
himself  may  feel  it,  and  it  will  be  readily  made 
out  by  palpation  at  the  affected  part.  (See  p. 
23.)  It  is  most  commonly  heard  over  the 
lower  half  of  the  chest,  about  the  lateral 
region  or  posteriorly.  But  it  must  be  remem- 
bered, that  should  the  friction  be  very  fine,  it 
may  not  be  with  certainty  recognisable  as 
such.  It  may  be  impossible  to  say  whether 
the  sound  is  extra  or  intra-pulmonary,  to  say 


VOCAL  KESONANCE.  73 

whether  even  as  a  sound  it  is  moist  or  dry, 
and  we  express  our  difficulty  by  the  con- 
venient word  "  sub-crepitant "  or  "  muco- 
crepitant." 

Cateo^oricallv  friction  sound  is  described  as 
being — (1)  Superficial  in  character,  (2)  Gener- 
ally limited  in  area,  (3)  Never  influenced  b}^ 
coughing,  and  (4)  Possibly  modified  by  posture. 
Rales,  as  a  rule,  present  exactly  the  opposite 
characters. 

Vocal  Resonance. 

Having  completed  our  consideration  of  the 
breath  sounds  we  pass  now  to  the  Voice 
Sounds,  or : — 

Vocal  Resonance.  By  this  we  mean  the 
sound  of  another's  voice  as  heard  on  applying 
the  ear  or  the  stethoscope  to  the  surface 
of  his  chest.  In  the  healthy  chest,  if  we 
keep  away  from  the  main  bronchi,  we  find 
that  the  spoken  words  resolve  themselves  into 
a  mere  confused  buzzing.  The  character  of 
the  sound  will  difier  but  slightly  in  different 
people.  It  is  louder  in  the  male,  but  a  little 
less  indistinct  in  the  female.      It  is  the  more 


74        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

pronounced  the  deeper  the  tone  of  voice,  the 
more  capacious  the  chest,  and  the  thinner  the 
chest  wall.  Fat  and  muscle  interfere  with  the 
transmission  of  the  sound. 

In  testing  the  Vocal  Resonance,  or  the  V.R., 
it  is  usual  to  employ  a  uniform  set  of  words 
or  numbers,  such  as  "one,  two,  three,"  or 
"  ninety-eight,  ninety-nine,"  which  we  ask  the 
patient  to  repeat.  If  we  listen  in  the  areas 
over  the  right  and  left  bronchi,  over  the  right 
especially,  we  find  the  Y.R.  is  more  loudly, 
more  directly  conveyed  to  our  ear  than  else- 
where. We  have  in  this  situation  "increased 
V.R.,"  as  we  say,  and  if  we  heard  it  similarly 
increased  at  any  other  part  of  the  chest,  we 
would  say  there  is  hroncho'phony. 

In  disease  the  V.R.  may  be  altered  both  in 
degree  and  quality. 

The  V.R.  may  he  increased.  There  must 
be,  in  that  case,  a  more  uniform  medium  of 
conduction  than  there  is  naturally.  Practi- 
cally it  must  be  either  consolidation  or  cavity. 
Pneumonic  and  tubercular  consolidation  are 
the  two  most  common  forms  ;  but  a  lunsr 
compressed  against  the  chest  wall  posteriorly, 


BKONCIIOrilONY  AND  PECTORILOQUY.         75 

as  by  fluid,  is  a  not  unfrequent  cause.  But 
the  larger  bronchi  or  many  of  the  smaller, 
must  not  be  occluded,  for  then  the  waves  of 
sound  from  the  larynx  are  to  a  greater  or  less 
degree  stopped.  These  are  just  the  conditions 
which  determine,  as  we  have  seen,  the  amount 
ofV.Fr. 

A  pulmonic  cavity  is  also  a  cause  of  increased 
y.R.  It  need  not  be  large,  but  there  must  be 
the  same  free  communication  with  the  larynx 
that  we  have  just  seen  is  essential  in  the  case 
of  consolidation.  The  cavity  must  also  be 
either  near  the  surface  of  the  lung,  or  else 
have  a  conducting  layer  of  consolidation 
between  itself  and  the  surface.  A  cavity, 
unlike  consolidation,  is  not  usually  so  large  as 
to  lead  to  increased  V.Fr. 

There  are  two  words  which  express  with 
comparative  exactness  the  extent  of  the  in- 
crease. BronchopJiony  we  have  already  noted, 
but  the  highest  degree  of  increase  is  called 
pectoriloquy,  conveying,  as  it  does,  the  im- 
pression that  the  patient  is  speaking  right 
from  his  chest  into  the  stethoscope.  Like 
the   R.M.   or   a   rale,  under'  such   conditions, 


76        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

the  sound  is  articulate.  Mere  intensity  of 
conduction,  mere  loudness,  is  not  exactly  the 
element  that  we  consider  here,  but  distinct- 
ness; and  loudness  of  the  voice  itself  only 
confuses  the  point  at  issue.  We  try  rather 
the  whispered  voice,  and  we  find  that  it  elicits 
the  articulate  quality  in  the  highest  degree. 
Each  term  stands  for  a  definite  enough  pheno- 
menon and  the  beginner  should  simply  apply 
the  test  suggested  by  its  derivation. 

The  V.R.  may  he  diminished.  This  is  most 
likely  to  be  due  to  the  presence  of  liquid  or 
air  in  the  pleural  cavity.  Or  the  wave  of 
sound  may  be  intercepted  in  a  main  bronchus 
which  is  occluded  in  some  way,  as  by  the 
pressure  of  an  aortic  aneurism  or  other 
tumour  about  the  root  of  the  lung;  or  it 
may  be  that  several  smaller  bronchi  are  filled 
with  secretion.  If  the  amount  of  fluid  is 
considerable  the  V.R.  is  altogether  suppressed. 

Baccelli  has  shown  that  the  more  fluid  and  homogeneous 
the  effusion,  the  more  easily  and  completely  is  it  pene- 
trated by  the  vocal  vibrations,  and  that,  in  favourable 
circumstances,  even  a  whisper  maybe  audible  through  the 
effusion ;  but  through  fibrinous  and  particularly  through 
purulent  exudation  the  waves  of  sound  pass  with  difficulty 


iEGoriiONv.  77 

or  not  at  all.  Douglas  Powell  says  this  statement  only 
holils  true  in  certain  cases,  and  that  the  whisper  may 
sometimes  be  heard  through  purulent  fluid.  To  appreciate 
these  ditierences  in  conduction  Baccelli  recommends  that 
the  auscultating  ear  should  be  pressed  firmly  against  the 
chest,  that  the  other  ear  should  be  closed  with  the  point 
of  the  finger,  and  that  when  the  patient  speaks  he  should 
turn  away  from  the  examiner. 

The  V.R.  may  he  altered  in  quality.  Vari- 
ous ill-defined  changes  in  quality  may  be 
heard  along  with  bronchophony^ ;  sometimes  a 
kind  of  concentrated  buzzing,  or  again  rather 
a  sniifing  sound.  Several  times  in  lobar- 
pneumonia  it  has  seemed  to  me  exactly  like 
the  sound  obtained  by  blowing  on  a  comb 
covered  with  silk  paper. 

It  has  been  likened  also  to  the  voice  heard 
through  a  speaking-trumpet,  or  to  the  sound 
we  make  when  attempting  to  speak  with 
something  between  the  lips  and  the  teeth. 
But  all  these  forms  may  be  classed  under  one 
universally  recognised  title,  namely :  ^go- 
phony  {m^,  aiyo^,  a  goat ;  (pcovi'i,  a  sound),  the 
bleating  sound,  or  punchinello  voice.  Such 
illustrations  as  have  just  been  given,  will 
convey  to  the  student  a  better  idea  of  the 
kind   of    sound   he   is   to   expect    than    any 


Y8        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

detailed  description  can  do.  It  will  be  under- 
stood that  the  sounds  are  not  always  the  same 
or  even  similar,  yet  a  tremulous,  bleating, 
nasal  character  pervades  them  all.  It  is  heard 
over  a  much  more  limited  area  than  broncho- 
phony or  pectoriloquy.  It  is  practically 
confined  to  the  neighbourhood  of  the  inferior 
angle  of  the  scapula,  although,  in  rare  cases, 
it  may  be  heard  round  almost  to  the  nipple 
(Walshe).  True  segophony  is  considered  to 
be  characteristic  of  pleuritic  effusion  in 
moderate  amount,  and  it  is  believed  to  mark 
the  upper  limit  of  the  fluid,  or  where  it  is  still 
forming  but  a  thin  layer  between  the  pleural 
surfaces.  Its  peculiar  character  is  believed  to 
depend  on  the  voice  causing  a  vibration  of  the 
walls  of  the  bronchi,  flattened  and  compressed 
by  the  liquid  effusion,  and  these  vibrations 
coming  through  a  thin  layer  of  fluid  to  the  ear 
acquire  a  nasal  character  (Guttmann). 

SUCCUSSION. 

We  need  only  refer  to  this  in  a  sentence  or 
two.  If  a  large  cavity  contains  both  liquid 
and  air  (and  we  have  the  best  example  of  this 


SUCCUSSION.  79 

in  the  disease  called  hydro-pneumo-thorax), 
and  the  patient  is  shaken  or  moves  himself 
freely  while  we  listen  with  our  ear  to  the 
chest,  a  splashing  sound  may  often  be  heard 
such  as  we  get  by  shaking  a  glass  vessel  in 
which  there  is  a  little  water.  It  may  be  so 
distinct  that  the  patient,  and  even  those 
standing  near  his  bed,  may  hear  it.  This 
method  of  diagnosis  was  practised  by  Hippo- 
crates and  is  therefore  generally  called  Hijrpo- 
cratic  Succussion. 


80        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 


THE  PHYSICAL  EXAMINATION  OF 
THE  HEAET. 

In  the  examination  of  the  heart  we  proceed 
by  the  same  methods  and  in  the  same  order  as 
in  the  case  of  the  lungs,  namely,  by  inspection, 
palpation,  percussion,  and  auscultation.  The 
heart,  however,  more  than  the  lungs,  requires 
a  ready  reference  to  particular  points  on  the 
chest  wall.  The  student  should  therefore 
make  himself  familiar  with  the  ribs  and 
spaces  anteriorly  so  as  to  be  able  to  recognise 
any  one  of  them  without  difficulty. 

Normal  Relation  of  the  Heart  to  the 
Chest  Wall. 

The  most  certain  and  also  the  most  rapid 
method  of  counting  the  ribs  and  spaces,  say 
on  the  left  side,  is  to  place  the  palm  of  the  left 
hand  on  the  sternum,  and,  keeping  the  little 
finger  in  the  first  intercostal  space,  run  the 
other  fingers  down  the  corresponding  spaces, 
till  the  thumb  is  placed  on  the  fifth,  in  which 


THE  CAKDIAC  APEX  BEAT.         81 

we  shall  find  the  normal  inferior  limit  of  the 
heart  itself 

The  apex  beat  at  once  arrests  our  attention. 
From  every  standpoint  it  is  the  most  con- 
spicuous, the  most  significant,  and  in  the 
normal  condition,  the  most  constant  feature  of 
cardiac  physiognomy.  It  is  the  key  to  the 
position  of  the  heart.  It  tells  us  most  readily 
of  the  disturbinof  forces  that  are  attackinoj  the 
heart  either  from  within  or  from  without,  for 
while  the  base  is  the  most  fixed,  the  apex  is 
the  most  free  to  move  or  be  moved  in  any 
direction. 

Position  of  the  apex  beat. — Normally  it  is 
situated  in  the  fifth  intercostal  space,  or  just 
behind  the  upper  border  of  the  sixth  rib  on 
the  left  side.  It  should  be  a  little  further 
below  the  nipple  than  it  is  within  the  vertical 
nipple  line,  or  about  IJ  inch  below  and 
I  inch  to  the  right  of  the  nipple ;  for  it  will  be 
remembered  that  the  latter  does  not  occupy  a 
fixed  point.  The  beat  extends  over  an  area  of 
about  an  inch  square,  and  it  is  formed  in  the 
main  by  a  small  portion  of  the  left  ventricle. 

If  the  apex  beat  is  rather  diff"used,  then  the 


82        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

point  of  pulsation  furthest  to  the  left  is  to  be 
regarded  as  the  apex.  By  lying  on  the  left 
side  the  apex  is  brought  nearer  the  chest  wall 
and  the  impulse  made  more  distinct ;  it  is,  at 
the  same  time,  carried  a  very  little  towards 
the  left.  We  therefore  move  the  patient  on  to 
his  left  side  if  the  beat  is  faint  or  imper- 
ceptible in  the  dorsal  position;  and  if  still  in 
doubt,  we  endeavour  to  ascertain  its  position 
by  auscultation.  The  apex  beat  terminates 
the  long  axis  of  the  heart,  the  long  axis  itself 
being  directed  downwards,  slightly  forwards 
and  markedly  to  the  left. 

The  base  of  the  heart — This  measures  about 
three  inches,  and  is  pretty  equally  divided  by 
the  middle  line.  Being  at  right  angles  to  the 
long  axis,  it  looks,  not  directly  upwards,  but 
somewhat  to  the  right  so  that  the  left  auricle 
is  the  hisfher  of  the  two.  It  reaches  almost  to 
the  lower  edge  of  the  second  left  costal  carti- 
lage; the  right  only  to  the  upper  border  of 
the  third  right  costal  cartilage. 

The  left  border  of  the  heart  will  be  pretty 
accurately  followed  by  drawing,  from  the  left 
extremity  of  the  base  line,  a  line  convex  out- 


THE  CARDIAC  OUTLINE.  83 

wards  so  as  almost  to  touch  the  nipple,  and 
then  curving  it  slightly  inwards  to  the  apex. 
The  right  border  cannot  be  so  definitely 
sketched,  as  the  heart  rounds  gradually  back- 
wards, but  the  furthest  point  to  the  right  is 
about  midway  between  the  mesial  and  right 
nipple  lines,  or  an  inch  fully  to  the  right  of 
the  sternum.  The  inferior  border  of  the  heart 
ascends  with  but  a  slight  departure  from  the 
horizontal  to  join  the  right  border.  The 
above  may  be  taken  as  the  normal  outline  of 
the  heart,  always  remembering  that  the  apex 
beat  is  the  only  point  we  are  able  actually, 
that  is  clinically,  to  fix. 

INSPECTION. 

In  Health,  there  is  no  precordial  bulging  of 
the  chest  wall.  In  the  dorsal  decubitus,  the 
impulse,  if  visible  at  all,  is  confined  to  the  apex 
beat,  unless  the  patient  be  of  spare  build,  when 
it  may  be  seen  also  in  the  space  above  :  there 
is  practically  never  epigastric  pulsation. 

In  Disease. — Bulging  of  the  precordial 
region  indicates  that  there  has  been  undue 
impulse  over  a  considerable  period  while  the 


84        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

chest  wall  was  comparatively  plastic.  In 
children,  therefore,  and  still  more  readily  in 
children  suffering  from  rickets,  cardiac  hyper- 
trophy, or  pericardial  effusion  may  induce  this 
deformity.  It  is  rare  to  find  it  occurring  in 
adult  life.  It  is  likely  to  be  associated  with 
widening  of  the  intercostal  spaces ;  indeed 
this  may  occur  from  cardiac  hypertrophy 
although  there  is  no  bulging. 

The  impulse  area  is  increased,  but  within 
normal  precordial  limits,  by  physical  or 
mental  excitement;  and  permanently  when 
there  is  retraction  of  the  over-lapping  pul- 
monary border.  The  impulse  may  then  be 
seen  in  the  fourth  or  even  the  third  intercostal 
space.  Or  it  may  be  diffused  beyond  the 
normal  cardiac  area  from  hj^pertrophy  or 
dilatation. 

The  impulse  area  is  diminished  or  disap- 
pears when  the  cardiac  action  is  weakened,  as 
from  prolonged  illness  or  in  the  later  stages  of 
an  acute  disease.  Or  it  may  be  that  an 
emphysematous  lung  or  pleuritic  effusion 
comes  between  the  heart  and  the  chest  wall. 
In  pericardial  effusion  also,  we  may  find  the 


THE  CAKDIAC  AREA.  85 

intercostal  spaces  levelled  and  the  parietes 
raised  from  the  heart  as  it  were,  so  that  the 
apex  beat  becomes  possibly  imperceptible. 
But  it  might,  on  the  other  hand,  be  simply 
owing  to  excess  of  fet  in  the  parietes  of  the 
chest. 

The  im'pulse  area  is  displaced. — The  most 
potent  cause  of  this  is  pleuritic  effusion.  It 
pushes  the  heart  before  it  as  a  whole,  and  there- 
fore the  apex  most  markedly,  to  one  or  other 
side.  Left  pleuritic  effusion  may  cause  the 
apex  beat  to  be  felt  even  in  the  right  nipple 
line.  Effusion  on  the  right  side  may  carry  it 
to  the  left  axillary  line.  Air  in  one  or  other 
yjleural  cavity  acts  in  the  same  way. 

Aneurism  of  the  ascending  aorta,  if  large, 
will  displace  the  heart  downwards  in  its  long 
axis ;  and  generally  whatever  raises  or  lowers 
the  diaphragm,  raises  or  lowers  the  heart,  and 
therefore  the  apex  beat.  Pericardial  effusion, 
if  in  considerable  amount  and  uncomplicated, 
raises  and  carries  outwards  the  apex  beat,  so 
that  it  might  possibly  be  felt  in  the  fourth 
intercostal  space  and  in  the  nipple  line,  if 
indeed  it  could  be  made  out  at  all. 


86        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

PALPATION. 

In  the  physical  examination  of  the  heart 
inspection  and  palpation  go  hand  in  hand. 
The  one  supplements  and,  it  may  be,  corrects 
the  other.  We  try  again  if  the  beat  is  sharp 
or  prolonged,  punctuate  or  diffuse.  But  pal- 
pation does  more.  It  tests  the  force  of  the 
impulse,  and  we  also  feel  if  there  is  anything 
like  a  thrill  or  vibration  conveyed  to  the  chest 
wall.  This  impulse  marks  the  beginning  of 
the  ventricular  systole,  a  fact  that,  as  we 
shall  see,  may  be  of  great  value  in  verifying 
the  rhythm  of  a  cardiac  murmur.  The  ven- 
tricular contraction  is  synchronous  on  both 
sides;  it  is  a  movement  towards  the  chest 
wall  and  also  downwards,  with  a  slight  wave 
from  left  to  right. 

In  Disease. 

The  Impulse  Force  is  increased.  The  great 
cause  of  this  is  hypertrophy,  the  degree  of 
force  being  strictly  according  to  the  degree  of 
pure  hypertrophy,  that  is  hypertrophy  with- 
out dilatation  or  degeneration  of  the  cardiac 


THE  CARDIAC  IMPULSE.  87 

wall.  If  this  forcible  impulse  is  carried 
downwards  and  outwards,  namely,  in  the  axis 
of  the  heart,  prolonged  possibly  to  the  seventh 
or  even  the  eighth  intercostal  space,  it  will 
point  to  hypertrophy  of  the  left  ventricle.  If 
it  is  more  a  transverse  increase,  being  rather 
carried  down  by  the  sternum,  or  perhaps  into 
the  epigastrium,  it  will  indicate  right  ven- 
tricular hypertrophy.  It  is  likely  to  be  more 
forcible  and  heavier  in  the  former  than  in  the 
latter  case,  as  the  left  side  has  naturally 
thickened  walls  and  greater  contractile  power 
than  the  right. 

The  imjjulse  area  is  increased  luithout 
corresponding  increase  in  force. — Here  dila- 
tation is  suggested.  The  purer  the  dilatation — 
that  is,  the  less  there  is  of  hypertrophy — the 
weaker,  the  shorter,  the  more  fluttering  the 
impulse.  There  is  no  longer  the  idea  of 
power  as  in  hypertrophy ;  there  is  the  reality 
of  failure,  and  the  heart  trembles.  Other 
physical  signs  are  brought  out  by  auscultation 
as  we  shall  see  shortly. 

It  must  be  remembered  that  hypertrophy 
and  dilatation  are  as  a  rule  combined  and  in 


88        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

varying  proportions,  and  that  we  can  only 
judge  approximately  of  these  proportions  by  a 
careful  study  of  both  symptoms  and  signs. 
But  as  Walshe  summarises  it,  having  regard 
to  palpation  alone,  **  pure  hypertrophy  in- 
creases to  its  maximum  the  force  of  impulse ; 
h3^pertrophy  with  dilatation,  the  force  and 
area  combined  ;  dilatation  weakens  force, 
extends  area." 

Whether  or  not  the  auricles  can  be  so 
hypertrophied  as  by  themselves  to  cause  a 
precordial  impulse  is  not  agreed.  If  we  could 
make  out  a  pulsation  over  either  auricle, 
which  preceded  by  an  instant  the  ventricular 
impulse,  it  would  lend  support  to  an  affirma- 
tive answer. 

Cardiac  Thrills  are  cardiac  murmurs  and 
cardiac  friction  sounds  which  are  felt  as  well 
as  heard.  It  is  better  therefore  to  study  them 
in  connection  with  the  sounds  themselves,  and 
we  need  only  here  make  a  general  reference  to 
them.  The  thrill  of  endo-cardial  origin  fre- 
quently gives  to  the  hand  a  sensation  which, 
was  likened  by  Laennec  to  the  purring  of  a 
cat,  and  it  has   since   been   pretty  generally 


CAKDIAC  I'EKCUSSION.  89 

known  as  the  fremissement  cataire.  It  occurs 
most  usually  at  the  apex,  running  up  to  and 
ending  with  the  first  sound ;  but  it  may  be 
felt  during  any  part  of  the  cardiac  cycle. 
Exceptionally  the  valvular  disorder  may  be  of 
such  a  character  as  to  produce  a  distinct  rasp- 
ins^  fremitus  throuo-h  the  manuhrinim  sterni. 
Pericardial  thrill  is  simply  an  accident  of 
pericardial  friction.     (See  p.  119.) 

I  have  felt  what  was  distinctly  a  vibration  over  the 
precordium  when  no  cardiac  murmur  whatever  could  be 
made  out. 

PERCUSSION. 

In  Health. 

The  percussion  of  the  heart  is  hardly  of  the 
same  character  as  that  of  the  lung.  It  is  not 
so  much  to  test  the  individual  part  as  to  mark 
the  outline  of  the  whole.  And  this  is  not  so 
easy.  From  all  sides  the  lung  flows  and  ebbs 
on  its  surface  with  every  act  of  respiration ; 
and  while  one  form  of  pulmonary  disease  ma}^ 
leave  the  heart  unduly  exposed,  another  may 
completely  cover  it  in.  Nor  does  the  heart 
present  a  flat  surface  for  examination,  but  one 


90        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

which  has  a  strong  convex  curve  transversely 
as  the  heart  rounds  deeply  within  the  chest. 
These  conditions  once  more  demand  a  constant 
study  of  the  normal  heart  to  which  the  follow- 
ing directions  can  at  best  be  only  a  guide. 
Two  areas  must  be  carefully  distinguished; 
the  exposed  surface  of  the  heart,  and  the  parts 
overlapped  by  lung. 

1.  The  exposed  surface  of  the  heart. — This 
consists  practically  of  the  right  ventricle,  the 
apex  being  the  only  part  of  the  left  ventricle 
which  comes  round  to  the  front.  It  is  some- 
what triangular,  and  extends  upwards  to  the 
level  of  the  upper  margin  of  the  fourth  costal 
cartilage  in  the  middle  line.  Thence  its  right 
border  falls  perpendicularly,  that  is,  down  the 
middle  line,  while  the  left  runs  straight  to  the 
apex.  The  base  coincides  with  the  inferior 
border  of  the  heart  as  far  to  the  right  as  the 
middle  line.  This  forms  the  area  of  super- 
ficial or  absolute  dulness.  Obviously  it  is 
affected  by  respiration;  indeed  by  forced 
inspiration  the  heart  may  be  completely  over- 
lapped by  lung.  The  area  we  have  been 
assuming,  and  have  just  described,  is  that  of 


AREA  OF  COMPARATIVE   DULNESS.  91 

moderate  inspiration.  Under  ordinary  circum- 
stances the  actual  dulness  hardly  extends  to 
the  middle  line  on  account  of  the  percussion 
vibrations  of  the  sternum  itself  This  could 
be  in  part  corrected,  were  there  any  need  for 
it,  by  making  the  patient  incline  incon- 
veniently forward,  thus  bringing  the  heart  in 
closer  contact  with  the  chest  wall. 

2.  The  lung-covered  surface  of  the  heart. 
— This  forms  the  area  of  deep  or  comparative 
dulness.  Here  there  are  insuperable  diffi- 
culties in  the  way  of  accurate  demarcation. 
The  heart  rapidly  recedes  on  the  right  side 
under  the  sternum,  which  yields  its  own  note 
on  percussion.  To  the  lower  right  there  is  the 
hepatic  dulness  with  which  that  of  the  heart 
is  continuous.  Sometimes  a  distinction,  some- 
times an  actual  break  in  the  character  of  the 
dulness  can  be  made  out  by  experts,  although 
the  discrimination  is  possibly  materially  aided 
by  knowing  that  a  line  drawn  along  the  upper 
margin  of  hepatic  dulness  to  the  apex  of  the 
heart  will  traverse  the  cardiac  boundary. 
Nor  can  much  be  made  of  any  alteration  that 
would  readily  occur  about   the   base    of  the 


92        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

heart.  For  these  reasons  it  is  usually  the  area 
of  superficial  dulness  that  is  examined  in 
cardiac  disease. 

In  Disease. 

The  superficial  area  of  dulness  may  first  of 
all  be  altered  from  pulmonary  disease.  In 
phthisis,  collapse,  or  any  form  of  contraction  of 
the  lung,  there  may  be  undue  exposure  of  the 
heart,  while  pulmonary  emphysema,  especially 
of  the  anterior  borders  may  completely  cover 
in  the  heart.  In  that  rare  disease  also, 
pneumo-pericardium,  a  more  or  less  tympanitic 
note  obtains  over  the  precordial  region. 

The  great  causes  of  increased  cardiac  dulness 
are  hypertrophy  and  dilatation.  After  what 
was  said  under  Palpation,  it  is  hardly  necessary 
to  describe  the  directions  in  which  the  increase 
may  occur. 

For  practical  purposes  it  is  usual  to  percuss 
the  heart  vertically  one  inch  to  the  left  of  the 
sternum,  by  which  we  avoid  the  main  vessels 
at  the  base,  and  transversely  along  the  level  of 
the  lower  margin  of  the  fourth  rib.  For  the 
diagnosis  of  left  ventricular  enlargement  Fagge 


INCREASED  CARDIAC  DULNESS.  93 

recommended  percussing  in  a  line  from  the 
fourth  costal  cartilage,  near  the  sternum  to  the 
site  of  the  apex  beat,  and  then  along  another 
line,  at  right  angles  to  the  former,  drawn  from 
the  lower  end  of  the  sternum,  upwards  and 
outwards,  to  a  point  at  which  the  absolute 
cardiac  dulness  ceases.  Normally,  the  first 
line  will  not  exceed  2  J  inches,  while  in  enlarge- 
ment it  may  extend  to  4  or  5  inches.  The 
second  line  should  measure  about  IJ  inch  : 
it  may  be  increased  to  more  than  2  inches. 

Pericardial  effusion  is  another  cause  of 
increased  cardiac  dulness,  and  should  the 
amount  of  fluid  be  considerable,  the  area  of  dul- 
ness will  assume  a  characteristic  cone-shaped 
form,  the  base  of  which  will  be  below  and  the 
apex  above.  This  depends  on  the  fact  that 
the  pericardial  base  is  on  the  level  of  the 
cardiac  apex,  aiad  the  pericardial  apex  at  the 
cardiac  base.  More  correctly,  the  dulness  will 
reach  the  level  of  the  lower  margin  of  the 
sixth  rib.  In  extreme  cases  the  effusion  may 
push  down  the  diaphragm,  extend  from  the 
right  of  sternum  to  the  left  axillary  region, 
widely  separate  the  lungs  where  they  normally 


94    .    ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

approximate,  and  reach  higher  than  the  cardiac 
base.  The  pathognomonic  sign  of  pericardial 
effusion  is  the  fact  of  dulness  extending  to  the 
left  of  the  apex  beat. 

AUSCULTATION. 

The  auscultation  of  the  heart  is  the  master- 
subject  of  physical  diagnosis.  So  exact,  so 
elaborate,  so  refined  has  it  grown,  that  the 
student  instinctively  approaches  it  with  mis- 
giving. Here  again  there  is  but  one  way.  We 
must  first  study  the  normal  state,  then  the 
grosser  departures  from  health,  and  then  the 
intricacies  of  finer  and  more  subtle  disorders. 
And  so  beginning  with  healthy  phenomena  we 
consider  first : — 

Cardiac  Sounds.  Each  beat  of  the  heart  as 
we  all  know  is  made  up  of  two  sounds  followed 
by  a  pause ;  this  complete  revolution  is  usually 
termed  the  cardiac  cycle.  The  two  sounds  are 
evidently  not  alike.  The  first  is  prolonged, 
with  more  volume,  yet  duller;  the  second  is 
short  yet  sharp.  The  word  "  lubb-tup "  is 
usually  selected  to  imitate  them.  Wherever 
the  sounds  are  heard,  it  will  be  noticed  that  as 


CARDIAC  SOUNDS.  95 

regards  quantity  the  first  sound  is  always  long 
and  the  second  always  short ;  but  it  is  not  so 
as  regards  accent.  With  a  little  care  the 
accent  can  be  made  out  to  be  on  the  first  sound 
at  the  apex  (lubb'-tup),  while  at  the  base  it  is 
on  the  second  sound  (lubb-tup'). 

It  is  misleading  to  say  that  at  the  apex  the  rhythm  is 
trochaic  ( —  —),  and  at  the  base  iambic  (-—  — ).  It  is  not 
so  in  the  classical  sense,  and  in  musical  rhythm,  time  and 
accent  are,  of  course,  quite  different  things.  It  is  far 
from  being  a  mere  scholastic  distinction.  On  the  contrary" 
it  will  not  be  unprofitable  for  the  student  to  endeavour  to 
make  out  clearly,  that  while  the  first  sound  is  always  long 
in  quantity,  it  may  or  may  not  be  accentuated. 

The  first  sound  is  coincident  with  the 
beginning  of  the  ventricular  systole,  the  second 
sound  with  the  beginning  of  the  ventricular 
diastole,  while  during  the  pause,  or  perhaps 
only  towards  the  end  of  the  pause,  the  auricles 
ara  silently  contracting. 

The  relative  duration  of  the  difierent  periods 
within  the  cardiac  cycle  cannot  be  exactly 
estimated.  In  the  case  of  the  normally  beating 
heart  the  pause  is  longer  than  either  the 
ventricular  systole  or  diastole,  but  probably 
hardly    so   long   as   the  two  combined.     The 


96        ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

diastole  is  shorter  than  the  systole.  The 
auricular  systole  is  generally  believed  to 
occupy  a  very  short  period  immediately  before 
the  first  sound.  If  the  heart's  action  is 
quickened  it  is  chiefly  the  period  of  rest  that 
is  shortened. 

The  physical  cause  of  the  heart  sounds  is  a 
physiological  rather  than  a  clinical  question. 
Still  the  clinical  student,  with  possibly  a 
fading  recollection  of  the  numerous  and  diverse 
theories  that  have  been  advanced,  will  with 
advantage  remember  this,  that  muscular  con- 
traction plays  at  least  a  considerable  part  in 
the  production  of  the  first  sound  (closure  of  the 
auriculo-ventricular  valves  is  generally  held  to 
be  the  main  factor),  and  that  the  second  sound 
is  due  to  the  closure  of  the  aortic  and 
pulmonary  semi-lunar  valves.  This  should  be 
recalled  when  studying  the  altered  sounds  of 
cardiac  hypertrophy  and  dilatation  (p.  99). 

As  to  the  valvular  element  in  the  sounds  it 
is  generally  agreed  at  what  points  the  different 
parts  of  the  sound  produced  at  each  orifice  may 
best  be  heard.  But  again  the  student  will 
first  of  all  remind  himself  of  their  anatomical 


AREA  OF  CARDIAC  SOUNDS.        97 

situation.  A  line  drawn  from  the  upper 
border  of  the  third  left  sterno-costal  articula- 
tion to  the  fourth  right  intercostal  space  will 
cross  the  pulmonary,  aortic,  mitral,  and  tri- 
cuspid orifices,  and  in  the  order  named.  A 
superficial  area  of  half  an  inch  square,  or  the 
bell  of  the  stethoscope,  will  cover  a  portion 
of  all  four  (Walshe). 

But  it  is  not  here  that  we  listen  to  the 
sound  of  each  orifice.  Overlapped  by  lung  and 
lying  at  various  depths  in  the  thorax,  their 
sounds  are  conducted  to  very  different  points 
on  the  chest  wall.  These  points  are  as 
follows  : — (1)  Mitral  sounds  are  sought  for  at 
the  apex ;  (2)  Those  of  the  tricuspid  valve  at 
the  lower  end  of  the  sternum ;  (3)  The  aortic  in 
the  second  right,  and  (4)  The  pulmonary  in 
the  second  left  intercostal  space  close  to  the 
sternum.^  This  has  a  still  more  practical  con- 
nection with  the  study  of  cardiac  murmurs, 
(See  p.  110,  note.) 

^  The  second  right  costal  cartilage  is  commonly  called 
the  "  aortic  cartilage,"  as  there  we  frequently  listen  to  the 
aortic  diastolic  sound  or  murmur. 


G 


98      essentials  of  physical  diagnosis. 

Alterations  in  the  Heart  Sounds. 

The  heart  sounds  may  be  altered  in  amount 
and  in  character. 

1.  In  Amount. — Whatever  weakens  the 
heart,  weakens  the  sounds,  the  first  sound 
especially  (Gee).  General  debility,  therefore, 
faintness,  febrile  prostration,  and  of  the  heart 
itself,  fatty  degeneratioD,  may  all  be  mani- 
fested in  this  way.  Both  sounds  of  the  heart 
are  weakened  rather  by  some  intervening 
medium  which  lessens  their  conduction,  as 
excess  of  fat  or  muscle  in  the  chest  wall,  and 
pericardial  effusion. 

On  the  other  hand  both  sounds  are  intensi- 
fied in  patients  of  spare  build,  and  compara- 
tively, in  the  young ;  also  by  mental  or 
physical  excitement ;  and  in  certain  neuroses, 
as  exophthalmic  goitre.  When  impulse  and 
sound  increase  together  there  is  probably  no 
hypertrophy,  but  only  a  more  forcible  action 
generally.  It  is  more  characteristic  of  cardiac 
disease  when  one  or  other  sound  alone  is 
affected,  unless  the  alteration  in  the  intensity 
of  the  two  sounds  is   in  different  directions. 


CHANGES  IN  CARDIAC  SOUNDS.  99 

Hypertrophy  weakens  the  first  sound  abso- 
lutely, or  imparts  a  dull  or  muffled  quality  to 
the  sound  while  conveying  the  impression  of 
increased  volume.  On  the  other  hand  a  short, 
sharp,  clearer  first  sound  indicates  dilatation  ; 
the  sound  will  be  smaller  but  more  defined. 
If  it  is  both  loud  and  sharp  there  is  probably 
hypertrophy  and  dilatation  combined. 

We  see  now  how  the  effect  of  hypertrophy  and  of  dilata- 
tion on  the  first  sound  is  better  understood  by  remember- 
ing the  two  elements  in  its  production  (p.  96).  The 
thickened  heavy  wall  of  hypertrophy  will  give  a  fuller  yet 
slower  and  duller  sound  itself,  at  the  same  time  concealmg 
the  valvular  element,  while  the  purer  the  dilatation  the 
more  will  the  short,  sharp  valvular  sound  predominate. 

The  second  sound  may  also  be  altered  in 
amount.  It  is  exaggerated  or  accentuated  by 
cardiac  hypertrophy.  It  should  be  listened  to 
both  over  the  aortic  and  pulmonary  area,  and 
"the  two  sounds  compared.  A  preponderance  of 
the  pulmonary,  or  a  marked  preponderance  of 
the  aortic  sound,  points  to  h^^pertrophy  of  the 
corresponding  ventricle,  the  aortic  sound  being- 
normally  only  slightly  the  louder  of  the  two. 
But  as  hypertrophy  probably  always  means  the 
presence  of  undue  obstruction  felt  by  the  heart, 


100     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

it  follows  that  the  causes  of  such  obstruction 
become  the  causes  of  this  accentuation.  Here 
we  need  only  mention  two.  Chronic  Bright's 
disease  is  well  known  to  induce  left  cardiac 
hypertrophy,  while  mitral  disease  is  a  great 
cause  of  right  cardiac  hypertrophy.  In  the 
two  cases,  therefore,  we  have  respectively  the 
aortic  and  the  pulmonary  sound  accentuated, 
and  this  arises  from  increased  vascular  ten- 
sion, in  the  one  case  systemic,  in  the  other 
pulmonary. 

Further  details  belong  rather  to  Hypertrophy  as  a 
special  disease.  The  apparent  difficulty  of  the  subject  be- 
comes its  surpassing  interest  only  when  we  become  familiar 
with  those  diseases  which  affect  the  circulation,  and 
understand  how  the  integrity  of  the  whole  depends  on 
that  of  any  one  part.  This  will  be  referred  to  more  fully 
in  speaking  of  cardiac  murmurs. 

The  second  sound  of  the  heart  is  rarely 
weakened  apart  from  the  first.  Mitral  dis- 
ease may,  however,  weaken  the  aortic  second 
sound  by  lessening  the  amount  of  blood 
which  is  driven  into  the  aorta,  and  conse- 
quently the  amount  which  recoils  on  the 
valve. 

2.    The    heart    sounds    may  be    altered  in 


REDUPLICATION.  101 

character.  The  most  obvious  change  in  this 
respect  is  Rediijjlication.  By  this  is  meant 
a  doubling  (rarely  a  trebling)  of  one  or  other 
heart  sound  (rarely  of  both  sounds).  It  is 
fairly  common,  not  very  difficult  to  detect, 
and  not  always  a  sign  of  disease.  Redupli- 
cation of  the  second  sound  is  the  more  com- 
mon of  the  two,  and  that  sound  being  natur- 
ally the  more  defined,  the  repeat,  like  a  faint 
echo  of  the  original,  is  readily  made  out, 
especially  if  the  cardiac  action  is  slow.  Re- 
duplication of  the  second  sound  is  of  com- 
mon occurrence  with  mitral  disease,  with 
diseases  of  the  lung  which  impede  its  circu- 
lation, and  is  therefore  commonly  associated 
with  accentuation  of  that  sound.  It  occurs 
sometimes  in  health  when  a  little  exercise 
readily  dispels  it  by  quickening  the  heart's 
action.  Some  forms  of  reduplication  run  into 
murmurs  when  the  heart's  action  is  thus  in- 
creased. 

A  cantering  action  (the  hriiit  cle  galoiD  of 
Potain)  of  the  heart  is  occasioned  sometimes 
by  a  doubling  of  the  first  sound.  It  is  heard 
down  the  left  border  of  sternum  or  towards 


102     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

the  apex,  and  seems  to  be  formed  by  a 
fainter  pre-systolic  sound  being  added  to  the 
normal  systolic.  It  has  been  described  by 
some  as  occurring  in  the  middle  of  the 
pause.  Potain  believed  it  to  be  commonly 
associated  with  cardiac  hypertrophy  from 
cirrhosis  of  the  kidney.  More  recently  (1885) 
he  has  considered  it  to  be  due  to  sudden 
diastolic  tension  of  the  ventricular  wal\ 
rather  than  from  hypertrophy  of  the  auricle 
as  he  formerly  held. 

Its  immediate  cause  can  only  be  a  matter  of  theory. 
This  winter  I  heard  a  distinct  slow  canter-sound  (redupli- 
cation of  the  first  sound)  just  under  the  middle  third  of 
the  clavicle  in  a  young  man  who  was  under  my  care  in  the 
Royal  Infirmary  suffering  from  a  trifling  complaint  not 
connected  with  the  heart.  The  reduplication  became  less 
distinct  towards  the  aortic  cartilage  where  it  was  just 
audible.  Below  this  point  it  could  not  be  heard,  and  it 
disappeared  altogether  by  making  the  patient  sit  up  in  bed, 
thereby  quickening  the  cardiac  action. 

The  mechanism  of  all  forms  of  reduplica- 
tion is  purely  a  matter  of  inference.  There 
are  two  generally  accepted  theories : — 

(1)  Non-synchronous  contraction  of  the 
two  ventricles.  Against  this  there  is  the  fact 
that  it  is  extremely  rare  to  find  both  sounds 


MECHA^'ISM  OF  REDUPLICATION.  10 


Q 


doubled,  and  it  fails  to  account  for  the  occa- 
sional trebling  of  one  sound,  which  is  known 
as  the  "  drum-beat "  or  the  "  rat-tat-tat "  sound. 
(2)  In  the  case  of  the  first  sound,  non-syn- 
chronous tension  of  the  different  valve  seg- 
ments of  the  auriculo-ventricular  orifice,  and 
in  the  case  of  the  second  sound,  probably  a 
non- synchronous  action  of  the  aortic  and 
pulvionary  valves  as  a  ivhole.  Whatever  be 
the  correct  view,  there  can  be  little  doubt 
that  unequal  tension  of  the  two  systems,  the 
systemic  and  the  pulmonary,  is  apt  to  induce 
reduplication.  Doubling  of  the  second  sound 
is  a  common  occurrence  in  those  conditions 
which  cause,  or  in  which  we  would  expect 
accentuation,  such  as  mitral  disease  or  chronic 
pulmonary  disease  in  which  the  pulmonic 
circulation  is  impeded,  that  is,  its  tension 
increased.  Similarly  renal  disease,  such  as 
cirrhosis  of  the  kidney,  by  increasing  the 
systemic  tension,  causes,  as  we  have  seen, 
reduplication  of  the  first  sound. 

The  only  other  pure  change  of  character  in 
the  cardiac  sound  that  need  be  mentioned 
is: — 


104     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

A  Tuetallic  or  ringing  quality.  This  char- 
acter is  readily  imparted  to  the  cardiac  sounds 
by  the  presence  of  a  neighbouring  cavity. 
Pneumo-thorax  or  a  large  pulmonary  cavity  is 
most  likelv  to  do  this,  but  a  distended  stomach 
may  occasionally  be  the  cause.  In  pneumo- 
pericardium, Guttmann  says  the  sounds  ac- 
quire this  quality  to  the  highest  degree ;  but 
this  is  a  very  rare  condition,  and  one  still  more 
rarely  admitting  of  physical  examination. 

In  addition  we  frequently  hear  indeter- 
minate departures  from  the  normal  quality  of 
heart  sound  that  might  or  might  not  be  con- 
sidered a  murmur.  It  might  become  unmis- 
takably one  by  a  little  physical  exercise ; 
more  rarely  this  causes  the  suspected  murmur 
to  disappear. 

CAEDIAC  MUEMUES. 
A  cardiac  murmur  may  be  defined  as  a 
sound  added  to  or  supplanting  the  cardiac 
sound.  As  in  the  case  of  the  pulmonary  rale 
the  fundamental  sound  need  not  be  the  normal 
one,  but  whether  it  be  or  not,  the  murmur  is 
something  more  than  simply  a  change  in  the 


CAKDIAC  MURMURS.  105 

(jnality  of  that  sound,  though  practically  it 
may  be,  as  we  have  just  seen,  difficult  or 
impossible  sometimes  to  say  whether  we  have 
before  us  the  one  or  the  other.  Murmurs  like 
rales  are  of  the  most  varied  character.  Of  all 
degrees  of  intensity,  they  are  usually  of  a 
smooth  blowing  quality,  though  often  rough, 
harsh,  or  hissing.  Sometimes  they  give  a 
perfect  musical  tone  of  definite  pitch.  But 
unlike  rales  their  character  is  not  their  most 
important  feature  and  they  are  not  classified 
on  that  basis. 

We  have  first  of  all  a  broad  anatomical 
division  into  exdocaedial  and  pericardial 
MURMURS.      We   shall   consider  first : — 

Endocardial  Murmurs.  They  may  be 
caused  (1)  By  any  organic  or  structural 
change  that  affects  the  competence  of  an 
orifice.  These  are  therefore  termed  organic 
murmurs.  They  again  may  be,  and  com- 
monly are,  induced  by  direct  valvular  dis- 
ease, as  we  would  expect;  but  sometimes 
the  valves  and  the  orifice  altogether  are 
healthy,  but  are  rendered  incompetent  by 
neighbouring  mischief,  as  by  the  traction  of  a 


106     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

dilated  ventricle  on  one  side,  or  of  an  aneurism 
of  the  first  part  of  the  ascending  aorta  on  the 
other. 

Endocardial  Murmurs  again  may  be  caused 
(2)  By  a  mere  functional  wregularity  of 
cardiac  tone  or  contraction.  These  are  there- 
fore termed  inorganic  ov  functional  murmurs 
(ana3micy  hcemic,  etc.).  An  endocardial,  as 
distinguished  from  a  pericardial  murmur,  is 
always  exactly  synchronous  with  the  accom- 
panying cardiac  movement. 

To  proceed  now  in  our  practical  line  ot 
inquiry,  when  we  hear  a  murmur,  particularly 
though  not  exclusively  an  endocardial  mur- 
mur, we  consider  three  things  in  the  order 
named : — 1st.  Its  rhythm ;  2nd.  Its  area  and 
point  of  maximum  intensity ;  and  3rd.  Its 
conduction. 

1.  Rhythm. — This  must  always  be  not  only 
the  first  question  regarding  a  murmur,  but  a 
distinct  part  or  stage  of  the  whole  inquiry. 
By  the  term  '  rhythm,'  is  meant  the  place  in 
the  cardiac  cycle  which  the  murmur  occupies ; 
in  other  words,  the  relation  which  the  murmur 
bears  to  one  or  other  heart  sound. 


RHYTHM  OF  A  MURMUR.  107 

But  the  murmur  itself  may  occasion  a  new 
difficulty.  It  may  be  no  easy  matter  to  say 
which  is  first  and  which  is  second  sound. 
Should  there  be  even  onl}^  one  murmur 
present,  a  slight  change  in  the  quality  of  the 
remaining  sound  or  in  its  accentuation,  may 
make  it  impossible  to  say  by  the  ear  alone 
which  sound  it  is  we  are  hearing,  and  conse- 
quently at  what  part  in  the  cardiac  cycle  the 
murmur  comes  in.  We  must  then  either  note 
the  systolic  impulse,  which  we  can  usually  feel 
on  our  ear  as  we  auscultate,  or  place  our 
finger  on  the  carotid  artery  and  note  the 
impulse  there.  Either  of  course  coincides 
with  the  first  sound.  The  radial  pulse  must 
never  be  taken  for  such  a  purpose ;  there  is 
too  distinct  an  interval  between  it  and  the 
ventricular  systole. 

Now  as  regards  Rhythm  there  are  three 
distinct  kinds.  We  shall  consider  as  the  first 
of  the  three  : — 

1.  The  Presystolic  MuT7}iur  (Auricular- 
systolic,  or  A.S.  murmur — Gairdner). — This 
murmur  precedes,  runs  up  to,  but  does  not 
displace  the  first  sound,  with  which  it  ends 


108     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

abruptly.  It  does  not  supplant  or  displace 
the  sound.  In  character  it  is  rough  or  'pur- 
ring, rather  than  soft  or  blowing,  and  this 
special  feature  contributes  to  its  detection 
when  associated  with  others  so  that  the 
rhythm  is  obscured.  The  thrill  may  be  dis- 
tinctly communicated  to  the  chest  wall. 

This  murmur  may  begin  early  in  the  car- 
diac pause,  but  is  usually  confined  to  the 
latter  part  of  that  period,  increasing  in  in- 
tensity and  roughness  up  to  the  first  sound. 
It  is  the  least  stable  of  endocardial  murmurs, 
becoming  more  marked  with  increased  cardiac 
action  or  disappearing  as  the  heart  quietens 
down. 

2.  The  Systolic  Murmur  (Ventricular- 
systolic,  or  y.S.  murmur — Gairdner). — This 
is  the  most  common  murmur  of  the  three. 
It  replaces  and  follows  or  shades  off*  from 
the  first  sound.  It  and  those  of  the  third 
group  are  blowing  or  hissing  rather  than 
rough,  but  the  systolic  murmur  is  usually 
louder  but  less  prolonged  than  those  of  the 
next  group. 

3.  The    Diastolic    Murmur     (Ventricular- 


AREA  OF  A  MURMUR.  109 

diastolic,  or  V.D.  murmur — Gairdner). — This 
murmur  follows  or  shades  off  from  the  second 
sound,  and  therefore  encroaches  on  the  pause. 
It  is  of  a  soft  blowing,  or  sometimes  of  a 
hissing,  quality. 

Of  the  foregoing  three  classes,  any  two 
or  all  of  them  may  be  combined.  If  the 
pre-systolic  and  the  systolic  are  together  a 
break  is  seldom  discernible  by  which  the}^ 
can  be  separated.  What  is  heard  is  one 
long  murmur,  the  first  part  of  which  is  dis- 
tinctly rough  and  the  second  blowing.  The 
first  sound  itself  is  practically  lost  in  the 
murmur.  With  the  systolic  and  the  diastolic 
murmur  it  is  difierent.  Although  there  is 
not  the  complete  second  sound  between  them, 
there  is  a  distinct  break  which  along  with 
the  softer  quality  and  greater  prolongation 
of  the  diastolic,  makes  the  recognition  of  the 
combination  a  matter  of  no  great  difficulty. 

The  Area  or  Site  of  Murmur. — Having 
satisfied  ourselves  as  to  the  rhythm,  we 
come  now  to  a  distinct,  and  what  should 
always  be  a  subsequent,  inquiry,  namely, 
which  of  the  four  orifices  is  afiected,  or  are 


110     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

affected,  for  there  may  be  more  than  one/ 
With  this  question  it  will  be  convenient  to 
associate  also  the  conduction  of  the  murmur. 

(a)  The  Qnurmur  is  best  heard  at  the  apex. 
This  indicates  mitral  disease,  and  now  from 
the  standpoint,  not  of  rhythm  but  of  situa- 
tion, it  is  termed  a  mitral  murmur.  It  will 
usually  be  found  that  the  murmur  is  pretty 
much  limited  to  that  area  and  is  quite  in- 
audible at  the  base.  Having  made  out  that 
the  murmur  is  of  mitral  origin,  we  add  to 
that  fact  the  rhythm  of  the  murmur  in 
order  to  find  out  more  exactly  the  nature 
of  the  lesion. 

Here  we  must  make  a  digression  as  to 
the  method  in  which  the  inquiry  should  be 
made.  There  is  but  one  way,  and  that  is 
to  become  thoroughly  familiar  with  the  car- 
diac action  and  circulation  in  relation  to  the 
cardiac  sounds.  There  must  be  few  who 
have  felt  the  influence  of  Gairdner's  teaching 

^  The  question  of  area  cannot  be  kept  quite  apart  from 
the  study  of  a  murmur's  rhythm,  but  the  recollection  of 
the  areas  of  the  different  cardiac  sounds  (p.  97)  will  have 
suggested  the  various  points  at  which  the  murmur  may  be 
heard. 


RHYTHM  AND  AREA  CO^IBINED.  Ill 

on  this  subject,  who  have  ever  had  recourse 
to  any  artificial  aid  to  their  recollection  of 
cardiac  murmurs.  "  It  is  necessary,"  says 
that  authority,  ''not  only  to  know  the 
rhythm  of  the  heart  as  a  matter  of  theory, 
but  to  have  such  a  vivid  conception  of  it 
as  calls  up  immediately,  in  connection  with 
any  single  phenomenon,  the  whole  of  the 
others  with  which  it  is  in  relation." 

For  example,  keeping  strictly  to  the  rhythm 
in  the  first  instance,  we  come  to  the  conclusion 
that  the  murmur  is  S3^stolic,  i.e.,  that  it  follows 
the  first  sound.  We  then  note  that  it  is  at  the 
apex  we  hear  it,  or  hear  it  best,  and  so  it  must 
be  mitral.  What  is  the  heart  doing  immedi- 
ately after  the  first  sound  ?  It  is  contracting. 
And  if  in  place  of  getting  the  normal  sound  of 
the  mitral  valve  closure,  we  get  a  murmur,  it 
must  be  that  the  contracting  ventricle  is  driv- 
ing some  of  the  blood  back  through  the 
auriculo- ventricular  orifice  into  the  auricle, 
or,  as  we  say,  ''  It  is  a  case  of  mitral  regurgi- 
tation," speaking  with  reference  to  the  blood, 
or  "mitral  insufl&ciency,"  referring  to  the 
orifice. 


112     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

As  to  the  conduction  of  the  mitral  regurgi- 
tant murmur,  it  is  usually  carried  outwards 
towards  the  nipple  line  or  beyond  ifc  into  the 
axillary  region.  The  murmur  may  be  con- 
ducted even  round  to  the  back,  so  as  to  be 
heard  below  the  angle  of  the  scapula,  or 
upwards  along  the  vertebral  column. 

The  mitral  regurgitant  murmur,  according  to  Naunyn, 
is  not  unfrequently  heard  at  the  base,  and  this  depends, 
he  thinks,  on  a  consequent  hypertrophy  of  the  left  auricle, 
causing  the  appendix  to  impinge  on  the  parietes.  It  will 
do  so  in  the  second  intercostal  space  about  an  inch  and  a 
half  to  the  left  of  the  sternum,  and  to  this  point  it  will 
tend  to  conduct  the  sound.  (See  also  note  on  functional 
murmurs,  p.  118.) 

Let  US  suppose  once  more  that  while  the 
area  is  still  mitral,  the  rhythm  of  the  murmur 
is  pre-systolic,  i.e.,  it  precedes  or  runs  up  to  the 
first  sound.  What  is  the  heart  doing  immedi- 
ately before  the  first  sound  is  heard  ?  Its 
auricle  is  contracting.^  And  if  that  act  in 
place  of  being  a  noiseless  one,  is  accompanied 
by  a  murmur,  it  must  be  that  the  blood  is 

1  It  is  better  to  learn  the  different  murmurs,  in  the  first 
instance  as  if  there  were  but  one  auricle  and  one  ventricle, 
the  left.  For  the  very  same  reasoning  applies  to  the  right 
heart,  and  it  reminds  us  at  the  same  time  how  greatly 
more  common  are  left  than  right  cardiac  murmurs. 


RHYTHM  AND  AREA  COMBINED.     113 

meeting  with  some  obstruction  in  passing  into 
the  ventricle  through  the  auriculo-systolic 
orifice  ;  and  so  we  say,  "  It  is  a  case  of  mitral 
obstruction,"  referring  to  the  blood,  or  of 
mitral  stenosis  (constriction),  having  regard  to 
the  orifice. 

The  mitral  obstructive  murmur  can  hardly 
be  said  to  be  conducted  at  all.  If  not  strictly 
limited  to  the  apex,  it  is  carried  slightly 
downwards  and  inwards.  It  is  rarely  heard 
posteriorly. 

Still  confining  our  attention  to  the  left 
heart,  suppose  next  we  find  that  : — (b)  Tlie 
murmiLT  is  best  heard  at  the  base.  We  call  it 
an  aortic  murmur.  This  murmur,  while  heard 
at  the  base  generally,  is  usually  best  heard  at 
the  TnoMubrium  sterni,  or  possibly  to  the 
right  of  this  in  the  second  right  intercostal 
&pace,  or  over  the  second  right  costal  cartilage, 
called  for  that  reason  the  **  aortic  cartilao^e." 

Before  investigating  more  particularly  the 

area  and  conduction  of  this  murmur,  we  once 

more  proceed,  following  out  the  plan  alread}^ 

laid  down,  to  inquire  about  its  rhythm.     We 

find  it  is  systolic,  and  by  the  process  of  reason- 

H 


114     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

ing  already  described,  we  know  it  must  be 
aortic  obstruction  (or  stenosis). 

This  murmur  is  not  likely  to  be  best  heard 
to  the  right  of  the  sternum,  for  although  the 
aortic  orifice  is  almost  directly  under  the 
pulmonary,  we  remember  how  murmurs  are 
most  readily  conducted  in  the  direction  which 
the  blood  current  is  taking  at  the  moment. 
As  to  conduction,  it  is  characteristic  of  this 
murmur  to  be  carried  upwards  towards  the 
clavicle,  or  into  the  vessels  of  the  neck.  It  is 
not  usually  conveyed  in  any  other  direction, 
although  it  is  this  murmur  which,  is  occasion- 
ally carried  a  long  distance,  as  up  and  out  to 
the  shoulder,  and  even,  as  I  once  heard  it, 
down  to  the  elbow. 

Suppose,  again,  that  while  the  murmur  is  at 
the  base  it  is  not  systolic,  but  diastolic  in 
rhythm,  that  is,  it  displaces  and  follows  the 
second  sound,  we  conclude  it  is  an  aortic 
regurgitant  murmur,  or  a  case  of  aortic  insufii- 
ciency.  Its  conduction  is  in  exactly  the 
opposite  direction  to  that  of  the  aortic  ob- 
structive. In  place  of  being  carried  upwards, 
it  is  carried  down  the  sternum,  and  is  some- 


RIGHT  CARDIAC  MURMURS.  115 

times  heard  most  distinctly,  or  at  least  with 
undiminished  intensity  at  the  xiphoid  cartil- 
age. But  there  it  always  ends  abruptly  down- 
wards, though  it  is  sometimes  carried  a  little 
to  the  left  towards  the  apex. 

It  will  be  understood  now  that  if  there  be 
two  murmurs  at  the  base,  a  systolic  and  a 
diastolic,  whose  characters  we  have  already 
noted,  it  is  simply  aortic  obstruction  and  re- 
gurgitation combined,  just  as  a  prolonged 
murmur  at  the  apex,  whose  first  part  is  rough, 
leads  us  to  conclude  there  is  mitral  obstruction 
and  reofurofitation  combined. 

The  student  having  carefully  studied  and 
thought  out  cardiac  murmurs  as  if  they  were 
always  solely  on  the  left  side  of  the  heart,  will 
now  take  up  right  cardiac  murmurs.  He  will 
remember  that  a  right  cardiac  murmur  rarely 
occurs  alone,  and  that  the  accompanying  left 
cardiac  murmur  will  almost  certainly  so  pre- 
ponderate as  to  conceal  the  one  on  the  right. 
The  significance  of  the  particular  rhythm  is  of 
course  the  same  whatever  be  the  side  afiected, 
so  that  we  need  only  in  a  word  refer  to  the  two 
right  orifices,  the  tricuspid  and  the  pulmonic. 


116     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

The  Tricuspid  Murmur. —  It  is  usually 
stated  to  be  best  heard  at  the  lower  end  of 
the  sternum,  or,  according  to  Gairdner,  prac- 
tically over  the  exposed  part  of  the  right 
ventricle — in  other  words,  the  area  of  super- 
ficial cardiac  dulness.  On  this  area  the  aortic 
murmur  obviously  may  encroach,  but  it  will 
not  be  limited  above  by  the  third  or  fourth 
rib  as  this  one  is.  The  tricuspid  systolic  (or 
regurgitant)  is  much  more  common  than  the 
pre-systolic  (or  obstructive). 

The  valvular  incompetence  in  the  case  of 
the  right  heart  is  not  so  likely  to  be  from 
direct  structural  disease  as  in  the  case  of  the 
left  side.  Rather  it  will  be  some  form  of 
mitral  disease,  or  a  chronic  pulmonary  afiec- 
tion,  that  opposes  the  onward  current  of  the 
blood,  and  so  leads  to  right  ventricular  dila- 
tation, which,  in  turn,  will  have  induced  some 
kind  of  tension  or  dislocation,  and  therefore 
incompetence,  of  the  tricuspid  orifice. 

The  Pulmonic  Murmur. — This  murmur  is 
of  limited  area,  and  is  usually  best  heard  just 
where  we  hear  the  pulmonic  sound,  namely, 
in  the  second  left  intercostal  space,  close  to  the 


THE  FUNCTIONAL  MURMUR.  117 

sternum.  It  is  rarely  carried  along  the  ster- 
num or  into  the  vessels  at  the  neck.  The 
murmur  has  usually  a  superficial  character 
and  is  systolic  in  rhythm.  The  pulmonic 
diastolic  is  admitted  to  be  the  rarest  of  all 
murmurs. 

We  must  bear  in  mind  that  we  are  not  to  conclude, 
because  we  hear  a  systolic  murmur  best  to  the  left  of  the 
sternum,  that  it  is  necessarily  a  case  of  stenosis  of  the  pul- 
monic orifice.  Remembering  the  rarity  of  right  murmurs, 
we  shall  rather  infer  that  some  accidental  circumstance, 
probably  in  the  relation  of  the  heart  to  the  chest  wall  or 
to  the  lung  at  that  point,  has  led  to  what  is  really  an 
aortic  murmur  being  best  heard  to  the  left,  in  place  of  to 
the  right  of  the  sternum. 

From  the  Organic  endocardial  murmur  we 
pass  now  to  the  Inorganic,  or,  as  it  is  usually 
termed  : — 

The  Functional  or  Ancemic  Mitrmiir. — It 
is  so  called,  as  we  already  said,  because  it 
depends  on  a  mere  functional  irregularity  of 
cardiac  tone  or  contraction.  No  organic  change 
is  ever  found  in  the  heart,  and,  as  it  occurs  in 
the  weak  and  anaemic,  it  is  reasonable  to 
suppose  that  the  murmur  is  caused  simply 
by  a  departure  from  that  perfect  co-ordinate 
contraction  of  the  heart  that  is  characteristic 


118     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

of  the  normal  state ;  or,  as  Guttmann  tersely 
puts  it,  "  uniform  vibration  yields  sounds ; 
non-uniform  vibration,  murmurs."  This  mur- 
mur is  always  systolic,  and  of  a  feeble  soft 
quality.  It  comes  and  goes  more  readily  or 
completely  than  any  structural  murmur  will 
likely  do,  becoming  more  feeble  as  patient's 
strength  increases,  or  it  may  be  disappearing 
independently  of  any  improvement  in  the 
patient's  condition.  It  is  practically  always 
heard  at  the  base  of  the  heart,  sometimes  in 
the  aortic,  but  more  commonly  in  the  pulmonic 
area.  It  is  occasionally  carried  upwards  into 
the  vessels  of  the  neck. 

Dr.  Balfour,  of  Edinburgh,  says,  with  Hayden,  that 
this  murmur  has  no  definite  line  of  propagation  ;  and  that 
it  is  best  heard  in  the  second  intercostal  space,  one  and  a 
half  inch  or  more  to  the  left  of  the  sternum,  just  where 
the  hypertrophied  left  auricle  would  impinge  on  the  chest 
wall.  Following  Naunyn,  he  considers,  therefore,  that 
functional  murmurs  depend  on  mitral  regurgitation.  (See 
previous  note  on  Mitral  Regurgitation. )  The  above  view 
is  not  generally  held. 

Having  completed  our  reference  to  murmurs 
produced  within  the  heart,  we  pass  to  one 
that  is  formed  on  the  surface,  namely  : — 


THE  EXOCARDIAL  MURMUR.  119 

The  Pericardial  Murmur. — The  liealthy 
pericardium,  like  the  pleura,  is  soft  and 
smooth,  and  the  play  of  its  two  surfaces  is 
perfectly  noiseless.  But  disease  may  interfere, 
and  so  affect  these  surfaces  as  to  induce  this 
form  of  murmur.  The  pericardial  murmur  has 
very  distinctive  features.  It  is  grating  or 
rubbing,  as  pleural  friction  usually  is,  and  is 
never  soft  and  blowing,  like  the  endocardial 
murmur.  Compared  with  the  latter,  it  has  a 
superficial  articulate  character.  It  is  not  like 
the  endocardial  murmur  decisive,  absolutely 
synchronous  with  the  cardiac  movement,  but 
laoforinof — shufflino*  I  think,  is  the  best  word — 
like  one  who  cannot  keep  time.  It  is  the 
"to-and-fro"  sound  of  Sir  Thomas  Watson, 
the  murmur  being  nearly  always  double  :  if 
it  is  not  double  it  will  accompany  the  first 
sound.  It  is  likely  to  be  altered  by  changing 
the  position  of  the  patient  ;  for  example,  it 
may  be  abolished  by  making  the  patient  lie 
on  his  back,  or  be  intensified  by  turning  him 
on  his  left  side.  It  may  be  affected  also  by  a 
varying  pressure  of  the  stethoscope. 

Pericardial  murmurs  are  usually  heard  over 


120     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

the  exposed  surface  of  the  heart,  and  are  not 
carried  upwards  into  the  vessels  of  the  neck 
or  downwards  to  the  xiphoid  cartilage.  Peri- 
cardial friction  is  distinguished  from  pleural 
friction  by  the  latter  ceasing  when  the  patient 
holds  his  breath.  But  we  may  remind  our- 
selves, very  much  as  a  curiosity,  that  the 
sound  might  not  cease  on  holding  the  breath, 
and  yet  depend  on  a  roughening  of  a  part  of 
the  pleural  surface  in  contact  with  the  healthy 
pericardium. 

Latham  pointed  out  long  ago,  and  Guttmann  endorses 
the  statement,  that  even  an  endocardial  murmur  may,  in 
rare  cases,  be  made  louder  by  the  pressure  of  the  stetho- 
scope. Endocardial  murmurs,  too,  as  is  sometimes  said  of 
pericardial,  may  be  influenced  by  respiration.  One  can 
with  a  little  care  and  experience  make  out,  I  think  not 
unfrequently,  that  endocardial  murmurs  may  diminish  in 
intensity  with  inspiration  and  increase  with  expiration. 

Arterial  Sounds. — Over  the  carotid  and 
subclavian  arteries  the  two  sounds  of  the 
heart  are  usually  heard  in  health.  It  is  gener- 
ally considered  that  they  are  simply  the  heart 
sounds  transmitted,  though  there  are  ground^ 
for  supposing  that  the  first  may  be  in  part  de- 
veloped  locally.     I   once   heard,   and   it  was 


ARTERIAL  MURMURS.  121 

coiToborated  by  several  senior  students,  a  re- 
duplication of  the  first  sound  over  the  third 
part  of  the  right  subclavian  artery.  It  was 
hardly  audible  at  the  base  of  the  heart  on  the 
same  side,  and  quite  inaudible  lower  down,  or 
to  the  left. 

Arterial  Murmurs. — These  may  also  be 
heard  at  the  root  of  the  neck  in  the  same 
arteries.  The  murmur  may  be  brought  out 
here,  as  elsewhere,  by  the  pressure  of  the 
stethoscope,  and  may  also,  as  we  have  already 
seen,  be  transmitted  from  the  heart.  But  in 
many  cases  it  is  spontaneously  developed, 
although  in  what  way  is  not  very  clear.  The 
murmur  is  certainly  often  associated  with  con- 
solidation of  the  apex,  and  may  after  all  be 
caused  simply  by  the  pressure  of  the  subjacent 
lung. 

Venous  Stasis  and  Pulsation. — At  the  root 
of  the  neck  the  external  jugular  vein  may 
sometimes  be  seen  to  be  greatly  distended. 
This  may  be  but  a  part  of  a  general  venous 
plethora  from  intra-thoracic  pressure  (aneurism, 
malignant  disease,  etc.) ;  or  it  may  arise 
directly  from  distension  of  the  right  auricle. 


122     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

Again,  actual  pulsation  of  the  external 
jugular,  systolic  in  rhythm,  is  not  an  un- 
common phenomenon.  In  some  cases  it  would 
seem  to  be  communicated  from  the  neighbour- 
ing arteries,  though  the  typical  cause  is  tricus- 
pid regurgitation.  Sometimes  .  the  pulsation 
is  pre-systolic  in  rhythm,  and  is  supposed  to 
be  due  to  the  contraction  of  the  right  auricle. 

Venous  Murmurs. — They  are  also  chiefly 
heard  in  the  external  jugular.  They  may  be 
audible  to  some  degree  in  health,  but  are  com- 
monly and  always  most  markedly  heard  in 
angemic  women.  They  are  essentially  con- 
tinuous, and,  being  of  a  musical  quality,  the 
murmur  is  known  as  "  the  humming-top 
sound,"  or  the  hruit  de  diahle.  They  are 
much  better  heard  on  the  right  side,  and  when 
the  patient  is  erect. 


POSTURE  OF  PATIENT.         123 


THE  PHYSICAL  EXAMINATION  OF 
THE  ABDOMEN. 

The  physical  examination  of  the  abdomen^ 
though  conducted  on  the  same  principles  and 
by  the  same  methods  as  that  of  the  thorax, 
admits  of  a  greater  use  of  certain  of  these 
methods,  such  as  palpation,  and  of  the  almost 
complete  exclusion  of  one  of  them,  namely, 
auscultation.  The  more  yielding  character  of 
the  abdominal  wall  permits  much  more  being 
made  out  by  inspection  and  palpation,  while 
the  busy  action  of  the  thoracic  viscera  calls 
for  a  larger  employment  of  the  stethoscope 
than  do  the  silent  processes  of  the  organs 
within  the  abdomen. 

In  order  to  facilitate  the  examination  of 
the  abdomen  the  patient  should  be  in  bed, 
lying  on  his  back,  with  the  head  and 
shoulders  raised  and  the  legs  drawn  up,  sup- 
ported in  such  a  way  that  all  tension  of 
the  abdominal  wall  is  removed.  He  should 
breathe   freety   and    easily;   and    it   will    be 


124     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

found  that  the  period  of  expiration,  especi- 
ally towards  the  end  of  the  act,  is  the  most 
favourable,  at  least  for  palpation.  In  some 
rare  cases  anaesthetics  may  be  required. 

Regions  of  the  Abdomen. — The  abdomen, 
like  the  thorax,  has  been  artificially  divided 
into  regions,  though  with  more  reason,  for 
we  have  now  not  only  to  locate  certain 
lesions  in  an  organ,  but  a  number  of  dif- 
ferent organs  all  included  within  this  great 
division  of  the  body.  The  sub-division  is 
usually  made  by  the  following  lines. 

The  first  line  is  drawn  transversely  at  the 
level  of  the  most  prominent  point  of  the 
lower  costal  cartilages  on  either  side,  and 
the  second  parallel  to  this  at  the  level  of 
the  crest  of  the  ilium.  These  lines  are  again 
crossed  at  right  angles  by  two  lines,  each 
of  which  falls  perpendicularly  from  the  arch 
of  the  thorax  to  the  centre  of  Poupart's 
ligament. 

We  have  thus  three  zones,  each  of  which 
is  divided  by  the  perpendicular  lines  into 
three  parts. 

In  the  upper  zone  we  have  the  right  and 


REGIONS  OF  THE  ABDOMEN.  125 

left  hypochondrium,  with  the  epigastric  region 
between  ;  in  the  middle  zone,  the  right  and 
left  lumbar  regions,  with  the  umbilical  region 
between  ;  and  in  the  lower  zone,  the  right 
and  left  iliac  regions,  with  the  hypogastrium 
between. 

In  the  epigastric  region  there  is  the  body 
and  p3'loric  end  of  the  stomach,  and  the  left 
lobe  of  the  liver ;  and,  more  deeply,  the  pan- 
creas, the  hepatic  vessels,  the  coeliac  axis  and 
part  of  the  aorta.  Tn  the  right  hypochondric 
region,  the  right  lobe  of  the  liver  and  the 
gall-bladder ;  in  the  left  hypochondric  region, 
the  cardiac  end  of  the  stomach  and  the  spleen. 
In  the  umbilical  region  there  is  the  trans- 
verse colon  and  part  of  the  mesentery,  omen- 
tum, and  small  intestine ;  in  the  right  lumbar 
region,  the  ascending,  and  in  the  left,  the 
descending  colon,  with  the  corresponding 
kidney  in  each.  In  the  hypogastric  region 
there  is  the  small  intestine,  and  into  it  - 
ascends  the  distended  bladder.  In  the  left-  v^ 
iliac  region  there  is  the  coecum,  and  in  the 
^right  the  sigmoid  flexure  of  the  colon. 


H 


126     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

INSPECTION. 

The  general  contour  of  the  abdomen  varies 
within  normal  limits  in  different  individuals 
to  a  greater  degree  than  any  other  part  of 
the  body.  This  depends  chiefly  on  the 
amount  of  fat  there  is  in  the  parietes, 
though  it  is  also  frequently  owing  to  intes- 
tinal distension.  Attention  must  be  paid  to 
the  general  nutrition  in  order  to  judge  what 
is  natural,  and  what  is  actually  disease.  We 
might  find  other  evidence  of  disease  to  guide 
us  in  our  opinion,  such  as  enlargement  of 
the  superficial  veins  of  the  abdomen,  or 
dropsy  of  the  lower  limbs.  The  abdomen 
is  larger  relatively  to  the  size  of  the  chest 
in  children,  and  in  them  the  contrast  often 
becomes  very  striking. 

Enlargement. — If  arising  from  a  consider- 
able amount  of  sub-cutaneous  fat  or  oedema, 
the  umbilicus  will  be  sunken ;  if  from  an 
amount  of  fluid  in  the  peritoneal  cavity,  suffi- 
ciently great  to  cause  a  like  uniform  disten- 
sion, unaltered  by  change  of  posture,  the 
umbilicus  will  be  protruded  and   the  super- 


ENLARGEMENT  OF  ABDOMEN.  127 

ficial  veins,  more  or  less  distended,  will  be  seen, 
throuo^h  the  tense  and  thinned  skin  radiating 
in  all  directions  from  the  umbilical  region. 

When  this  fluid  in  the  peritoneal  cavity 
(ascites)  is  less  in  amount,  there  is  lateral 
bulging  as  the  patient  lies  on  his  back,  and 
on  a  change  of  posture  a  prominence  will  be 
observed  at  the  most  dependent  part.  On 
the  other  hand,  if  the  enlargement  be  from 
gaseous  distension  (meteorism,  tympanitis)  it 
will  be  uniform  in  all  positions.  This  con- 
dition is  one  of  the  abdominal  features  of 
enteric  fever,  and  in  children  it  is  a  symptom 
of  tabes  mesenterica,  although  in  them  it  may 
often  depend  on  simple  atony  of  the  parts. 
Localised  bulging  or  non-symmetrical  swelling, 
will  indicate  rather  an  enlarg-ement  con- 
nected  with  some  particular  organ.  The  dis- 
tension that  commonly  accompanies  intestinal 
obstruction  becomes  sooner  or  later  general, 
but  in  the  earlier  stages  is  more  likely  to 
be  just  above  the  seat  of  the  obstruction. 
In  these  circumstances  periodic  peristaltic 
movement  also  is  frequently  distinctly  seen 
accompanied  by  more  or  less  pain. 


128      ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

Depression  or  retraction  of  the  abdomen 
may  be  a  part  of  general  emaciation  ;  it  is 
strikingly  so  in  malignant  obstructive  disease 
of  the  stomach  or  upper  bowel.  It  is  charac- 
teristic of  the  later  stage  of  tubercular  men- 
ingitis in  children ;  the  abdomen  is  "  boat- 
shaped/'  as  it  is  termed.  This  is  thought  to 
be  due  to  intestinal  contraction  from  irrita- 
tion of  the  nerve  centres  v^hich  control  the 
bowel. 

The  movements  of  respiration  should  be 
noted.  Apart  from  the  difference  in  the 
sexes  already  referred  to,  they  are  lessened 
or  quite  arrested  in  painful  abdominal  affec- 
tions, such  as  acute  peritonitis  :  or  they  may 
be  mechanically  impeded  as  in  extreme  ascitic 
distension.  On  the  other  hand,  abdominal 
movement  is  increased  when  pulmonary  dis- 
ease restricts  thoracic  movement.  Any  abnor- 
mality in  the  appearance  of  the  skin  itself 
would,  of  course,  receive  attention. 

MENSUEATION. 

The  girth  of  the  abdomen  at  a  particular 
level,   for    example    at    or    so    many    inches 


POSTURE  FOR  PALPATION.  120 

above  or  below  the  umbilicus,  is  often  taken 
from  time  to  time  in  cases  of  enlarixement 
in  order  to  note  any  increase  or  decrease  as 
the  case  may  be.  We  would  thus  judge  if 
a  tumour  is  growing,  if  an  ascites  is  decreas- 
ing, and  so  on. 

PALPATION. 

In  the  case  of  the  abdomen,  palpation 
occupies  the  lirst  place  ;  just  as  auscultation 
does  in  the  examination  of  the  luno-s.  The 
patient  must  be  lying  in  bed  with  the  legs 
placed  as  already  indicated,  and  much  care 
and  tact  may  be  required  to  get  that  perfect 
relaxation  of  the  abdominal  walls,  that  is  so 
essential  to  a  thorough  investigation  by  this 
method.  The  patient  should  breathe  freely, 
and  the  end  of  each  expiration,  which  must, 
however,  be  natural  and  not  forced,  will  be 
found  to  be  the  most  favourable  moment  for 
examination.  The  attention  of  the  patient,  if 
he  be  nervous  or  excitable,  may  be  diverted 
by  conversation. 

In   acute  inflammations  of   the  abdominal 

viscera,   and   more  particularly    of  the   peri- 

I 


130     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

toneum,  there  is  always  pain  on  pressure ;  and 
firm  pressure  is  simply  unbearable.  The 
painful  area  may  be  general  or  localised,  and 
there  will  be  a  corresponding  degree  of  tension 
of  the  parietes  accompanying.  Pain  arising, 
on  the  other  hand,  from  intestinal  spasm,  dis- 
tension, or,  still  more  characteristically,  of  a 
neuralgic  character,  will  be  more  likely  to  be 
relieved  by  steady,  firm  pressure.  Circum- 
scribed median  pain  on  pressure  in  the  epigas- 
trium is  very  characteristic  of  gastric  ulcer. 

By  palpation  we  make  out  the  situation, 
outline,  and  consistence  of  viscera,  especially 
when  they  are  enlarged,  and  of  underlying 
tumours.  These  latter  may  be  in  the  parietes, 
and  if  so,  they  are  comparatively  fixed  :  they 
do  not  rise  up  and  down  with  the  respiratory 
movement  of  the  diaphragm,  nor  change  their 
position  with  an  altered  position  of  the  patient. 
The  tumour  may  be  within  the  rectus  muscle 
itself,  and  this  can  be  recognised,  as  Dr. 
Douglas  Powell  remarks,  by  keeping  the  hand 
over  the  tumour,  and  making  the  patient  raise 
himself  half  to  the  sitting  posture,  when  the 
tumour  will  start  forward  along  with  the  con- 


PALPATION  IN  ASCITES.  131 

tracting  recti.  Small  nodular  growths  are  often 
puzzling.  It  may  be  very  difficult  to  say 
whether  they  are  in  the  abdominal  wall,  or 
are  cancerous,  tubercular,  or  other  growths,  in 
the  peritoneum  or  its  folds. 

In  thin  people,  with  relaxed  w^alls,  the 
pulsation  of  the  abdominal  aorta  may  be  very 
readily  felt,  and  give  rise  to  the  suspicion  of 
aneurism  ;  and  not  unfrequently  the  nervous 
dyspeptic  himself  associates  this  '  beating ' 
with  the  peristaltic  movement  of  the  trans- 
verse colon,  and  imagines  that  at  last  he  has 
discovered  the  dreadful  cause  of  all  his  trouble. 

A  particular  form  of  palpation  is  practised 
in  the  diagnosis  of  ascites.  If  the  amount  of 
fluid  be  considerable,  so  that  we  have  a  con- 
dition just  short  of  extreme  tension,  the 
slightest  fillip  or  tap  on  one  side  of  the 
abdomen  causes  a  wave  which  is  distinctly 
felt  by  the  hand  placed  on  the  other  side. 
Should  the  parietes,  however,  be  loaded  with 
fat,  or  be  otherwise  unwieldy,  the  wave  will 
be  greatly  obscured.  The  fat  itself  may  give 
rise  to  a  sense  of  fluctuation,  and,  in  these 
circumstances,  it  is  recommended  that  another's 


132     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

hand,  or  a  piece  of  card-board,  be  firmly  pressed 
edgewise  on  the  surface  between  our  two 
hands,  so  that  any  possible  wave  from  the 
fatty  tissue  may  be  thereby  prevented. 

Should  the  fluid  come  between  the  moder- 
ately lax  abdominal  wall  and  a  solid  organ, 
such  as  the  liver,  we  ma}^  be  able,  by  a  sudden 
vertical  plunge  of  the  fingers,  to  get  through 
the  fluid,  as  it  were,  and  come  suddenly  on 
the  hard  unyielding  mass  beneath.  This  is 
easily  done,  and  its  significance  readily  appre- 
ciated. It  has  been  called  "dipping  for  the 
liver." 

PEECUSSION. 

The  normal  percussion  note  of  the  abdomen 
is  emphatically  tympanitic.  Theoretically, 
it  should  be  of  higher  pitch  over  the  colon 
than  over  the  stomach,  and  highest  of  all  over 
the  small  intestine ;  but  practically,  this  dis- 
tinction is  of  little  avail,  so  variable  is  the 
amount  of  their  solid,  fluid,  and  gaseous  con- 
tents, absolutely  and  relatively. 

Percussion,  like  palpation,  is  practised  for 
the  delimitation  of  organs  and  morbid  growths, 


PERCUSSION  IN  ASCITES.  133 

and  for  the  recognition  of  fluid  in  the  peri- 
toneal cavity.  In  the  case  of  solid  bodies 
particularly,  palpation  is  an  essential  accom- 
paniment of  percussion,  for  considering  the 
effect  of  the  overlapping  or  even  adjacent 
bowel,  it  will  often  keep  us  right  when 
percussion  alone  would  have  proved  a  doubt- 
ful guide. 

We  shall  only  at  this  point  refer  further  to 
the  percussion  note  in  ascites.  Here  the 
uniform  rule  and  guide  to  us  is,  that  we  shall 
get  dull  percussion  wherever  there  is  under- 
lying fluid,  and  that  the  fluid  being  free  in 
the  abdominal  cavity,  the  limits  of  dulness 
will  vary  with  the  varied  position  of  the 
patient.  But  here  again  the  hollow  viscera 
must  be  reckoned  with.  While  they  will 
always  tend  to  rise  to  the  surface  of  the  fluid, 
they  may  be  bound  down  to  some  extent  by 
adhesions,  or  may  be  compressed  by  the  large 
amount  of  fluid,  the  great  tension  of  the 
parietes  contributing  to  the  already  uniform 
dulness.  The  amount  of  fluid  may  be  so 
slight  that  it  can  only  be  detected  by  making 
the  patient  rest  on  his  knees  and  elbows,  and 


134     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 


SO  cause  it  to  gravitate  to  the  upper  anterior 
region  of  the  abdomen. 


AUSCULTATION. 

Auscultation  of  the  abdomen  is  of  little 
direct  value,  but  we  should  undoubtedly  be 
familiar  with  the  gastro-intestinal  sounds  in 
order  that  we  may  not  be  misled  when  they 
are  conducted  as  they  often  are  some  distance 
into  the  thorax.  Vascular  murmurs  are  occa- 
sionally heard  with  uterine  and  ovarian  tum- 
ours, and  friction  sounds  not  unfrequently 
arise  from  inflammatory  or  malignant  disease 
affecting  the  peritoneum  over  the  liver,  spleen, 
etc.,  or  the  surface  of  these  viscera  themselves. 

It  will  be  well  now  to  pass  to  the  examina- 
tion of  the  individual  organs  of  the  abdomen ; 
of  those  at  least  that  usually  come  within  the 
province  of  the  physician.  We  shall  consider 
first : — 

The  Liver. 

As  the  liver  winds  round  by  the  ribs  to 
the  right,  and  to  the  left  is  greatly  lost  in  the 
dulness   of  the   heart,   it   is  the   upper    and 


PERCUSSION  OF  LIVER.  135 

lower  boundaries  which  present  to  us  the 
most  definite  outline.  But  neither  is  very 
well  defined.  Above,  the  lung  dips  down  a 
little  way  in  front,  while  below  we  have  the 
transverse  colon  and  the  stomach  now  obtrud- 
ing their  tympanitic  note,  and  now  by  their 
more  solid  contents  obscuring  the  natural  line 
of  liver  dulness.  Still  in  ordinary  circum- 
stances the  depth  of  the  normal  liver  in 
front  is  easil}^  estimated. 

Following  a  definite  method  the  student 
will  do  well  to  begin  by  percussing  in  the 
vertical  line  of  the  right  nipple.  Being 
always  careful  to  percuss  from  clear  to  dull, 
he  will  do  this  from  above  downwards,  and 
about  the  fifth  intercostal  space  he  will  be 
sensible  of  a  commencing  comparative  dul- 
ness. This  superficial  or  comparative  dulness, 
indicating  the  area  where  the  lung  overlaps 
the  liver,  will  only  extend  to  an  inch  or 
even  less  downwards,  when  the  area  of  abso- 
lute hepatic  dulness  will  be  reached.  Percuss- 
ing now  from  below  upwards  he  will  usually 
find  that  in  this  vertical  line  the  lower  mar- 
gin corresponds  exactly  with  the  arch  of  the 


136     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

thorax,  and  that  the  depth  of  the  hepatic 
dulness  measures  there  4  inches  or  rather 
more.  From  this  line  the  upper  margin 
slightly  falls  and  the  lower  margin  rises,  till, 
in  the  middle  line,  the  vertical  dulness 
measures  only  3  inches;  roughly  speaking, 
it  extends  slightly  above  and  below  the 
xiphoid  cartilage.  Towards  the  axillary  line 
the  upper  margin  rises  very  slightly,  and  on 
reaching  it,  attains  also  its  highest  level,  while 
the  lower  border,  although  it  descends  a  little, 
leaves  the  arch  of  the  thorax  which  descends 
still  more  rapidly.  The  vertical  measurement 
in  the  axillary  line  is  therefore  greater  still, 
being  from  4 J  to  5  inches,  that  is  from  the 
seventh  intercostal  space  above  to  the  tenth 
intercostal  space  below.  Posteriorly  the  upper 
border  reaches  the  level  of  the  tenth  or 
eleventh  dorsal  vertebra,  while  the  lower  bor- 
der is  lost  in  the  dulness  of  the  kidney.  We 
have  already  given  the  line  of  separation 
between  heart  and  liver  as  indicated  by 
continuing  the  upper  margin  of  hepatic  dul- 
ness to  the  cardiac  apex.  In  making  a  rapid 
surve}^  of  the  liver  in   the  erect  posture  we 


ENLARGEMENTS  OF  LIVER.  lo7 

must  allow  for  a  little  depression  of  the  whole 
viscus. 

For  purposes  of  diagnosis,  especially  from 
pulmonary  disease,  the  upper  border  of  the 
normal  liver  should  be  familiar  to  the  student; 
he  should  always  remember  that  it  forms  a 
curved  line,  and  one  not  usually  altered  by 
disease  of  the  liver  itself.  It  is  the  lower 
margin  that  is  materially  altered  both  in 
the   case   of  enlargements   and   contractions. 

Before  referring  to  these  we  must  note  that 
the  liver  may  be  apparently  enlarged.  It  is 
naturally  larger  in  the  child  relatively,  and 
in  the  case  of  the  rickety  chest  it  may  appear 
to  be  enlarged  absolutely  by  being  displaced 
downwards  by  the  thoracic  deformity.  Tight- 
lacing  may  greatly  displace  the  liver,  and  it 
may  be  pushed  downwards  slightly  by  pul- 
monary emphysema,  pleuritic  effusion,  etc.  In 
the  case  of  pleuritic  effusion  the  upper  limit 
of  dulness  will  be  formed  by  the  fluid,  and 
will  thus  necessarily  assume  a  straight  and 
not  a  curved  line  when  the  patient  sits 
upright. 

The  liver  may  undergo  either  enlargement 


138     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

or  contraction ;  the  surface  may  retain  its 
normal  smooth  character,  or  become  nodular 
or  otherwise  irregular.  Palpation  is  now  of 
greater  service.  The  soft,  smooth,  uniformly 
enlarged  fatty  liver  with  its  rounded  lower 
margin,  perhaps  as  low  as  the  transverse  line 
of  the  umbilicus,  can  thus  be  made  out,  and 
also  the  amyloid  liver,  similarly  but  probably 
more  enlarged,  of  firmer  consistence,  and  with 
sharper,  more  defined  edge.  Abscess  and  ad- 
vanced hydatid  tumour  of  the  liver  will  tend 
to  present  a  yielding  globular  distension 
from  out  the  otherwise  enlarged  hepatic  area. 
In  the  case  of  the  latter,  by  placing  three 
fingers  over  the  swelling  and  percussing  the 
middle  one  we  may  get  the  characteristic 
vibration  known  as  hydatid  fremitus.  As 
regards  malignant  disease  we  usually  find 
some,  and  often  the  most  distinct,  irregularity 
of  surface  or  outline.  There  is  probably  pain, 
and  there  may  be  greater  enlargement  than 
is  met  with  in  any  other  hepatic  afiection — 
upwards  possibly,  which  is  always  the  ex- 
ception, as  well  as  downwards,  which  is  the 
rule.      Sometimes   no  unevenness   of  surface 


CONTRACTIONS  OF  LIVER.  139 

can  be  made  out ;  then  the  rapidity  of  growth 
and  pain  would  suggest  malignant  disease. 

The  contractions  of  the  liver  {acute  yelloiv 
atrophy,  and  chronic  atroiohy  or  cirrhosis)  do 
not  present  much  ground  for  physical  exam- 
ination. When  the  student  is  thorousjhlv 
familiar  with  the  hepatic  dulness  in  the 
mammary  line,  he  will  readily  detect  the 
suspicion  or  the  certainty  of  atrophy  as  the 
case  may  be  :  the  vertical  measurement  of 
absolute  dulness  may  be  no  more  than  a 
finger's  breadth.  The  presence  of  ascites  and 
enlargement  of  the  superficial  veins  would  cor- 
roborate the  diagnosis  of  chronic  atrophy. 

No  one  can  study  the  physical  examination  of  the  liver 
without  being  greatly  aided  by  Murchison's  classical  ex- 
position of  the  subject  in  his  Clinical  Lectures  on  Diseases 
of  the  Liver.  jSTothing  can  be  more  simple  than  his  divi- 
sion of  enlargements  into  j^'^'i'^less  and  painful,  the  former 
including  simple  hypertrophy,  fatty  Kver,  and  hydatid 
tumour ;  and  the  latter,  congestion,  catarrh  of  the  bile 
ducts,  hepatitis,  abscess,  and  cancer.  The  number  of  ex- 
ceptions one  meets  with  in  the  case  of  cancer  does  not,  in 
my  opinion,  prove  any  objection  to  his  classification.  The 
exceptions  impress  on  our  minds  the  fact  that  even  malig- 
nant disease  7nay  be  absolutely  painless.  Perhaps  "pain- 
less," as  applied  to  hydatid  tumour,  is  rather  misleading  ; 
at  least,  the  student  should  understand  that  before  he  sees 


140     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

the  case,  that  is,  before  it  is  likely  to  have  attracted  much 
attention,  it  will  probably  have  become  painful  in  some 
degree. 

The  Stomach. 

The  peculiarity  of  the  normal  stomach  is 
its  continually  varying  dimensions.  The  de- 
scription of  it  usually  given  is  that  of  the 
organ  moderately  filled.  It  lies  immediately 
under  the  anterior  wall  of  the  abdomen,  shaped 
very  much  like  a  bent  cone  ;  with  its  base  or 
fundus  in  the  left  hypochondrium,  the  body  in 
the  epigastrium,  and  the  pyloric  end  in  the 
right  hypochondrium.  The  base  or  fundus 
rises  well  up  in  the  thorax,  reaching  at  its 
upper  border  to  about  the  level  of  the  seventh 
rib,  while  the  pyloric  orifice  will  be  found  a 
little  below  the  lower  border  of  the  liver, 
within  a  line  drawn  from  the  right  nipple  to 
the  umbilicus  (Loomis).  The  stomach  measures 
from  12  to  15  inches  in  length  and  4  or  5 
inches  in  depth.  One  fourth  of  the  viscus 
lies  to  the  left  of  the  cardiac  orifice.  Besides 
the  possibility  of  great  distension,  the  attach- 
ments of  the  stomach  admit  of  its  being 
greatly  displaced.      It  may  be  pushed  down 


DILATATION  OF  STOMACH.  141 

into  the  hypogastrium,  or  allowed  to  rise  high 
up  into  the  lateral  region  of  the  thorax. 

It  is  mainly  by  percussion  and  succussion 
that  we  make  a  physical  examination  of  the 
stomach.  We  have  already  referred  to  the 
tympanitic  note  of  gaseous  distension  rising 
frequently  as  it  does  to  the  base  of  the  heart, 
and  elsewhere  running  into  the  similar  note  of 
the  surrounding  intestines.  Obviously  a  dull 
percussion  note  running  into  that  of  the  liver 
and  spleen  will  be  brought  out  if  there  be 
much  contained  solid  or  liquid  food,  whose 
presence  can  be  further  corroborated  by  suc- 
cussion. This  occurs  to  the  greatest  deo^ree  in 
pyloric  obstruction,  usually  malignant,  and  in 
chronic  dilatation  {atony)  of  the  stomach. 
Fagge  describes  an  acute  dilatation  of  the 
stomach  and  says  the  signs  are — (1)  A  rapidly 
increasing  distension  of  the  abdomen,  which  is 
uns3^mmetrical,  the  left  hypochondrium  being- 
full  while  the  right  is  comparatively  flattened. 
(2)  The  presence  of  a  surface  marking,  which 
descends  obliquely  from  the  left  hypochon- 
drium towards  the  umbilicus,  and  which 
corresponds  with  the  lesser  curvature  of  the 


142     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

stomach.  This  seems  to  move  up  and  down 
each  time  the  patient  breathes.  (3)  Dulness 
and  fluctuation  in  the  pubic  region  with  reson- 
ance over  the  front  of  the  abdomen.  (4)  The 
production  of  a  splashing  sound  on  manipula- 
tion. (Principles  and  Practice  of  Medicine, 
vol.  ii.  p.  118.) 

The  nodular  thickening  of  cancer  of  the 
pylorus  is  usually  made  out  easily  enough  by 
palpation,  but  malignant  disease  of  the  body 
of  the  stomach  does  not  as  a  rule  yield  very 
evident  signs,  while  implication  of  the  cardiac 
orifice  is  beyond  the  reach  of  any  kind  of 
external  examination. 

The  Spleen. 

The  spleen  does  not  greatly  obtrude  itself  on 
our  attention  by  proclaiming  either  its  pre- 
sence or  its  function  :  it  is  accordingly  rather 
neglected.  It  lies  obliquely  in  the  left  postero- 
lateral region  pretty  much  in  the  line  of  the 
ribs  ;  its  upper  and  anterior  border  following 
the  upper  margin  of  the  ninth  rib,  while  its 
lower  and  posterior  border  coincides  with  the 
lower  margin  of  the  eleventh  rib,  or  practically 


ENLARGEMENTS  OF  SPLEEN.  143 

with  the  lower  border  of  the  thorax.  Its  upper 
posterior  border  comes  near  to  the  vertebral 
column,  although  this  cannot  be  made  out 
clinically  ;  the  lower  anterior  extremity  will 
end  pretty  much  with  the  eleventh  rib.  But 
it  must  be  remembered  that  the  organ  varies 
considerably  within  normal  limits. 

Within  these  limits  we  can  only  avail  our- 
selves of  percussion  in  tracing  its  outline,  and 
even  by  that  method  we  must  not  expect  to 
ojet  the  broad  contrast  of  absolute  dulness 
which  the  much  more  bulky  liver  affords.  Its 
upper  and  anterior  border  is  the  most  readily 
distinguished  in  contrast  with  the  tympanitic 
note  of  the  stomach  and  bowel,  and  more  pos- 
teriorly we  come  down  upon  the  spleen  gradu- 
ally from  the  pulmonary  resonance  above.  If 
it  gets  below  the  arch  of  the  thorax,  palpa- 
tion- comes  to  our  aid,  except  well  round  to 
the  back,  where  it  lies  in  contact  with  the 
kidney. 

The  only  changes  we  need  consider  are 
enlargements.  As  these  take  place  downwards 
and  forwards,  a  rough-and-ready  test  is  to  see 
if  we  get  an  uninterrupted  line  of  clear  per- 


144     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

cussion  from  the  anterior  border  of  the  left 
axilla  down  to  the  nmbilicus.  The  spleen 
should  not  come  nearly  so  far  round  to  the 
front  as  to  encroach  on  that  line. 

An  enlarged  spleen  is  easily  made  out  inde- 
pendently of  percussion.  Its  smooth  surface, 
and  rounded,  yet  distinct,  edge,  which  is  often 
notched  anteriorly,  and  the  fact  that  it  can 
often  be  felt  in  the  lumbar  region  as  a  solid 
movable  mass  betw^een  the  two  hands,  make  it 
usually  easy  to  recognise.  In  still  greater 
degrees  of  enlargement  it  may  occupy  nearl}^ 
all  the  left  side  of  the  abdomen. 

The  spleen  is  enlarged  in  constitutional 
diseases,  that  is,  those  in  which  the  blood 
seems  to  be  primarily  affected.  In  the  acute 
fevers,  for  example,  and  more  particularly  in 
the  very  chronic  malarial  cachexia  with  its 
recurring  attacks  of  ague,  we  have  almost 
certainly  this  enlargement.  But  in  the  dis- 
order of  sanguification,  known  as  leucocy- 
themia,  we  have  the  spleen  attaining  its 
greatest  degree  of  enlargement,  having  in  some 
cases  so  completely  filled  the  left  side  of  the 
abdomen  as  to  have  been  mistaken  for  ovarian 


EXAMINATION   OF   KENAL    REGION.        145 

tumour.  The  spleen,  like  the  liver  and 
kidney,  is  liable  to  amyloid  enlargement,  the 
combined  implication  of  the  three  viscera 
being  an  important  element  in  the  diagnosis. 
Malignant  disease  is  the  only  other  affection 
likely  to  be  diagnosed  by  physical  examina- 
tion. It  is  said  by  Guttmann  that  a  spleen  of 
normal  size  may  be  greatly  displaced ;  even 
downwards  and  forwards  into  the  left  iliac 
fossa. 

The  Kidneys. 

These  organs  lie  close  to  the  spinal  column, 
at  about  the  level  of  the  two  lowest  dorsal,  and 
the  two  highest  lumbar  vertebrae,  the  right 
being  rather  the  higher  of  the  two.  They  are 
always  embedded  in  a  considerable  quantity 
of  fat,  and  being  also  beneath  the  thick  lumbar 
muscles  they  are  in  the  normal  state  beyond 
the  reach  of  either  inspection  or  palpation. 
Only  about  the  lower  half  of  the  outer  convex 
margin  can  be  defined  by  percussion  from  the 
adjacent  colon. 

In  diseased  conditions  inspection  can  only 
be  of  service  by  way  of  contrasting  the  two 


146     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 

sides.  By  this  means,  aided  by  palpation, 
great  enlargement,  as  from  cancer  or  hydrone- 
phrosis, might  be  made  out.  Conversely  we 
might  recognise  the  absence  of  the  kidney 
from  its  normal  situation,  it  being  displaced. 
But  by  palpation  less  degrees  of  enlargement 
can  be  recognised  by  placing  the  patient  in  the 
usual  position  on  his  back.  We  may  thus 
with  one  hand  posteriorly  be  able  to  tilt  the 
tumour  forwards  on  the  other  hand  pressed 
firmly  down  in  front,  or  even  catch  the  solid 
body  between  the  two  hands. 

We  can  rarely  by  physical  examination 
alone,  determine  between  the  different  forms 
of  enlargement.  They  need  not  be  here 
enumerated  in  full ;  but  the  most  common  or 
pronounced  are  cancer  of  the  kidney,  Hydrone- 
phrosis (distension  of  the  pelvis  of  the-  kidney 
by  retained  urine),  and  Pyonephrosis  (retention 
of  pus).  In  the  case  of  perinephritic  abscess, 
one  would  probably  be  able  to  recognise  its 
more  superficial  character,  and  possibly  be  able 
to  make  out  suppuration,  but  we  would  be 
also  guided  very  much  by  the  greater  pain  on 
pressure  and  the  higher  fever. 


THE    FLOATING    KIDNEY.  147 

Enlargement  of  the  right  kidney  might  be 
mistaken  for  f?ecal  accumulation  in  the 
ascending  colon,  cancer  of  the  pylorus,  a 
mesenteric  tumour,  or  enlargement  of  the 
right  ovary.  Enlargement  of  the  left  kidney 
might  be  thous^ht  to  be  an  enlargrement  of  the 
spleen  or  of  the  left  ovary,  or  fsecal  accumula- 
tion in  the  descending  colon. 

One  kidney,  or  even  both,  may  become  dis- 
placed and  fall  quite  out  of  its  normal  site, 
downwards  or  forwards.  The  right  kidney  is 
much  more  commonly  dislodged ;  and  this 
occurs  much  more  frequently  in  women.  The 
diagnosis  may  be  difficult  from  faecal  accumu- 
lation, mesenteric  tumour,  enlarged  spleen, 
distended  gall-bladder,  etc.,  but  its  peculiar 
shape  and  the  facility  with  which  it  falls 
forward  on  the  patient  leaning  forward  or  even 
on  sitting  up,  or  again  glides  away  from  the 
hand  back  into  its  normal  situation,  is  very 
characteristic,  besides  the  altered  physical  con- 
ditions at  its  natural  site.  One  would  be 
guided  also  by  the  sense  of  dragging,  or 
weight,  the  sickening  pain,  etc. 


148    essentials  of  physical  diagnosis. 

The  Panceeas. 

This  organ  lies  too  deep  for  physical  exam- 
ination with  any  degree  of  certainty.  Cancer- 
ous enlargement  may  sometimes  be  detected  in 
the  epigastrium  as  a  hard,  deep,  and  firmly 
rooted  mass,  but  the  disease  is  seldom  primary, 
i.e.  solitary,  and  therefore  anything  approach- 
ing a  positive  diagnosis  is  impossible. 

Ovarian  Tumour. 

These  tumours  would  hardly  come  within 
the  province  of  the  physician  were  it  not  that, 
being  as  a  rule  cystic,  they  must  be  diagnosed 
from  ordinary  ascites.  The  patient  does  not 
usually  present  herself  while  the  tumour  is 
still  distinctly  unilateral  and  low  down  in  the 
inguinal  region,  but  we  would  endeavour  to 
make  out  whether  or  not  there  was  a  history 
of  this  kind.  Quite  likely  no  reliable  informa- 
tion could  be  given  on  that  point.  Placing  the 
patient  in  the  dorsal  position,  we  would  then 
endeavour  to  make  out  if  there  is  lateral 
bulging,  as  in  ascites,  or  if  the  abdomen  still 
retains  its  undue   projection  forwards,  as   in 


OVAKIAN    TUMOUR.  149 

ovarian  tumour.  Then  on  percussion  in  the 
same  position  we  would  expect  in  the  case  of 
ascites  to  get  dulness  in  the  flanks,  and  a  clear 
tympanitic  note  centrally  in  front,  which  dul- 
ness would  change  to  the  most  dependent  part 
with  a  change  in  the  position  of  the  patient. 
All  this  would  negative  an  ovarian  cyst,  in 
which  we  would  expect  dulness  centrally,  and 
clear  percussion  in  the  flanks.  We  would 
endeavour  further  to  ascertain  if  the  wave  on 
percussion  could  be  made  to  pass  beyond  the 
limits  of  the  dulness,  as  in  ascites,  or  if  the 
limit  of  fluctuation  and  of  dulness  corre- 
sponded, as  in  ovarian  disease.  A  less  super- 
ficial character  of  wave  impulse  would  also 
suggest  a  cyst.  But  the  two  conditions  may 
be  combined,  and  then  only  an  exhaustive 
general  inquiry  beyond  the  limits  of  a  mere 
physical  examination,  would  sufiice  to  effect  a 
diagnosis. 


150     ESSENTIALS  OF  PHYSICAL  DIAGNOSIS. 


APPENDIX. 


The  Junior  Student  who  wishes  to  begin  the 
independent  reporting  of  Medical  Cases  may 
derive  some  assistance  from  the  accompanying 
Outline.  He  will  not  complain  of  its  being  too 
short,  and  I  am  convinced  that  when  the  Student 
gets  beyond  it  he  should  be  guided  by  his  know- 
ledge of  individual  diseases. 

The  words  within  curved  brackets  relate  to 
what  is  occasional  or  accidental ;  those  within 
square  brackets  are  explanatory. 


OUTLINE   FOR   EEPORTING. 

Name,  age,  occupation  (residence)  "  admitted 

complaining  of " 

^'  Patient  states  that,"  etc.  [how  present  illness  be- 
gan, e.g.,  relation  to  work,  confinement  to  bed, 
etc.;  when  (suddenly  or  gradually).] 


CASE  KEPORTING.  151 

Personal  History.  — [Scrofula ;  syphilis ;  acute 
fevers  from  childhood  onwards ;  Injuries ; 
General  Hygienic  conditions,  e.g.,  Habits,  oc- 
cupation, etc.]    (Confinements  and  Lactation.) 

Family  History. — Ages  of  those  living ;  Deaths 

and  causes.     N.B. — Hereditary  diseases,  e.g., 

Cancer,    Tuberculosis,     Eheumatism,     Gout, 

Syphilis ;    Nervous    and    Mental    Diseases ; 

Malformations. 

Put  ailments  in  patient's  own  words  in  ' ' " 

e.g.,  *'  bronchitis  "  may  be  phthisis. 

Physical  Examination. — General  appearance, 
e.g.,  well  nourished  or  emaciated;  pale  or 
florid.  Cyanosis  ;  Jaundice ;  Bronzing.  Ex- 
pression, e.g.,  as  to  pain,  etc.  Condition  of 
skin,  e.g.,  hot  or  dry,  cold  or  clammy,  and 
perspiration.  Cicatrices.  Temperature,  Eespi- 
ration.     (Height  and  AVeight.) 


Begin  with  the  System  chiefly  affected. 

Respiratory  System. — Symptoms,  Pain,  Cough, 
Dyspnoea,  etc.  Signs,  Decubitus,  number 
and  character  of  respirations.  [Inspection, 
Palpation,  Percussion,  and  Auscultation, 
(Mensuration  and  Succussion)] ;  Sputum. 


152     ESSENTIALS  OF   PHYSICAL  DIAGNOSIS. 

Circulatory  System. — Symptoms  and  signs  as 
above.     Rate  and  character  of  pulse. 

Digestive  System. — Appetite,  Nausea,  Vomiting, 
Pain  ;  their  reference  to  food.  Signs  as  above, 
but  rarely  Auscultation.     Tongue.     Stools. 

Nervous  System. — Pain  and  other  sensory  phe- 
nomena; Motor  phenomena;  Trophic  changes; 
Incoordination ;  Spasms,  clonic  or  tonic :  all 
these  may  be  general  or  partial  or  unilateral. 
Intellectual,  emotional  or  Moral  disorder. 

Genito-Urinary  System. — Pain,  difficulty,  fre- 
quency, etc.,  as  regards  Micturition  or  Men- 
struation. Pain  independently ;  its  character, 
direction,  etc. 

Urine — Colour,  transparency,  specific  gravity, 
deposit,  reaction,  amount.  Albumen,  sugar, 
bile,  blood. 


158 


INDEX. 


Abdomen,  physical  examination 

of,  123. 

regions  of,  124. 

inspection  of,  126. 

• enlargement  of,  126. 

retraction  of,  128. 

measurement  of,  12S. 

palpation  of,  129. 

tumours  of,  130. 

percussion  of,  132. 

auscviltation  of,  134. 

Abdominal   aorta,    pulsation    of, 

131. 
Absolute  dvilness    of   heart,    the 

area  of,  90. 
Accent  of  cardiac  sounds,  95. 
Aegophony,  77. 
Alar  chest,  the,  10. 
Amphoric  resonance,  43. 

respiration,  62. 

rale,  70. 

Anfemic  murmur,  the,  117. 

Aneurism  of  aorta,  So. 

Aortic  heart  sounds,  area  of,  97. 

cartilage,  the,  97,  113. 

murmurs,  113. 

stenosis,  114. 

regurgitation,  114. 

Apex  beat,  SI. 

murmurs,  110. 

Apices  (of  lungs)  in  phthisis,  20. 
Area  of  cardiac  murmurs,  109. 
Arterial  sounds,  120. 

murmurs,  121. 

Ascites,  inspection  in,  127. 

palpation  in,  131. 

percussion  in,  133. 

Auricular-systolic  murmur,   the, 

107. 
Auscultating,  method  of,  48. 
Auscultation,  pulmonary,  45. 

in  health,  49. 

in  disease,  54. 

cardiac,  94. 

abdominal,  134. 

Baccelli  on  vocal  resonance,  76. 


Balfour  oa  functional  murmurs, 

118. 

Barrel-shaped  chest,  the,  of  em- 
physema, 11. 

Beau  on  the  origin  of  the  respira- 
tory murmur,  53. 

Bell  sound,  the,  on  auscultation, 
70. 

Bilateral  deformities,  7. 

Bowel  obstruction,  signs  of,  127. 

Breath  sounds  (see  "  Respiratory 
murmur  "). 

Bronchial  respiration,  60. 

sound,  the,  51. 

Broncophony,  75. 

Bruit  de  diable,  122. 

de  galop,  101. 

de  pot  fele,  34,  35,  43. 

Bubbling  rale,  the,  66. 

Canter  sound,  the  (cardiac),  101. 
Cardiac  hypertrophy,  87,  99. 
impulse  and  breath  sounds, 

57. 

thrills,  88. 

sounds,  94. 

cause  of,  96. 

area  of,  97. 

alterations  in,  98-104. 

murmurs,  104. 

endocardial,  105-118. 

organic,  106,  etc. 

rhythm  of,  106. 

pre-systolic,  107. 

systolic,  108. 

diastolic,  109. 

area  of,  109-116. 

functional,  117. 

Case  reporting,  outline  for,  150. 
Cavernous  respiration,  62. 

rale,  70. 

Chest,  the,  transversely  furrowed, 

8. 

regions  of,  4. 

Cheyne-Stokes  respiration,  18. 

Clicking  r&le,  the,  67. 

Coats  on  respiratory  murmur,  53. 


154 


INDEX. 


Cogged-wheel  respiration,  56. 

Comparative  dulness  of  heai't,  the 
area  of,  91. 

Conduction  (propagation)  of  mit- 
ral regurgitation,  112. 

obstruction,  113. 

aortic  obstruction,  114. 

regurgitation,  114. 

Cooing  rale,  the,  65. 

Cracked-pot  sound,  34,  35,  48. 

Crackling  rale,  the,  70. 

Crepitant  rale,  the,  67. 

Cyrtometer,  the,  19. 

Deep  cardiac  dulness,  area  of,  91. 
Diagnosis,  physical  and  medical,2. 
Diastolic  murmur,  the,  108. 
Dilatation,  cardiac,  87,  99. 

gastric,  141. 

Dipping  for  the  liver,  132. 
Duchenne  on  the  inspiratory  mus- 
cles, 12. 

DuU-tympanitic  note,  the,  34,  42. 
Dulness  (pulmonary),  absolute,  40. 

comparative,  41. 

(cardiac)  in  health,  89-91. 

■ in  disease,  92-94. 

Echo,  metallic,  44. 
Emphysematous  chest,  the,  10. 

mechanism  of,  11. 

Endocardial  murmurs,  105-118. 
Enlargement  of  thorax,  bilateral, 

10. 

unilateral,  12. 

heart  (see  "  Hypertrophy  "). 

abdomen,  126. 

liver,  137. 

spleen,  144. 

kidney,  146. 

Epigastric  region,  125. 
Expiration  sound,   Hyde    Salter 

on,  52, 

prolonged,  58. 

Dr.  Jackson  on,  58. 

Fagge  on  gastric  dilatation,  141. 
Floating  kidney,  the,  147. 
Fr^missement  cataire,  the,  89. 
Fremitus,  vocal,  21. 

pleural,  23. 

bronchial,  24. 

Friction  sound  or  rdle,  71. 
Functional  cardiac  murmur,  the, 
117. 


Gairdner  on  the  study  of  percus- 
sion, 30. 

cardiac  murmurs,  110. 

Gairdner's  organ-pipe  rales,  65. 

tricuspid  area,  116. 

General  principles,  1-3. 

Gurgling  rale,  the,  70. 

Guttmann  on  metallic  cardiac 
sounds,  104. 

on  cardiac  sounds  and  mur- 
murs, 118,  120. 

Hsemic  murmur,  functional,  106, 
117. 

Harrison's  groove,  10. 

Harsh  respiration,  59. 

Heart,  relation  to  chest  wall,  80. 

apex  beat,  81 ;  base,  82. 

area  increased,  84  ;  dimin- 
ished, 84 ;  displaced,  85. 

sounds     (see      "  Cardiac 

sounds  "). 

Humming-top  sound,  122. 

Hyper-resonance,  41. 

Hypertrophy,  cardiac,  87,  99. 

Hypochondric  region,  the,  125. 

Hypogastric  region,  the,  125. 

Iliac  region,  the,  125. 
Immediate  percussion,  26. 

auscultation,  45. 

Impulse,  the  cardiac,  86. 
Indeterminate  rales,  69. 
Inspection  of  chest,  6. 
of  heart,  83. 

of  abdomen,  126. 

Intestinal  obstruction,  signs  of, 
127. 

Jackson,  Dr.,  on  prolonged  ex- 
piration sound,  58. 
Jerky  respiration,  56. 
Jugular  vein,  pulsation  in,  122. 

Kidney,  examination  of,  145. 
enlargements  of,  146. 

floating  or  displaced,  147. 

Liver,  dipping  for,  132. 

examination  of,  134. 

enlargements  of,  137. 

contractions  of,  139. 

Lumbar  region,  the,  125. 

Mechanism  of  rickety  chest,  9. 


INDEX. 


155 


Mechanism  of  reduplication  (car- 
diac), 102. 

Mediate  percussion,  26,  etc. 

auscultation,  46,  etc. 

Mensuration  of  chest,  19. 

of  abdomen,  128. 

Metallic  ring,  the,  35. 

echo,  44. 

bell  sound,  70. 

rale,  70. 

tinkling,  70. 

cardiac  sound,  104. 

Mitral  sounds,  area  of,  97. 

insufficiency  (regurgitation), 

111. 

stenosis  (obstruction),  113. 

Mixed  rales,  69. 

Movements  of  respiration,  13. 

Mucous  rale,  the,  66. 

Muco-crepitant  rale,  the,  69. 

Murchison  on  diseases  of  the 
liver,  139. 

Murmur,  the  pericardial,  119. 

Murmurs,  cardiac  (see  "Cardiac 
murmurs"). 

respiratory  (see  "Kespiratory 

murmurs  "). 

arterial,  121. 

venous,  122. 

Musical  sound  v.  noise,  31. 

Naunyn  on  the  mitral  regurgitant 

murmur,  112. 
Neck,  pulsation  in  vessels  of,  122. 

Organ-pipe  rales,  65 . 
Orifices,  cardiac,  area  of,  97. 
Outline  for  case  reporting,  150. 
Ovarian    tumour,    diagnosis    of, 
148. 

Palpation  of  chest,  20. 

heart,  86. 

abdomen,  129. 

Pancreas,  the,  148. 
Pectoriloquy,  75. 
Percussion,  24. 

method  of,  27,  36. 

study  of,  29. 

sounds,  30,  33. 

of  lungs  in  health,  38. 

in  disease,  40. 

resistance,  44. 

of  heart  in  health,  89. 

in  disease,  92. 


Percussion  of  abdomen,  132. 

Pericardial  murmur,  the,  119. 

Peritonitis,  palpation  in,  129,  130. 

Pigeon-brotist,  the,  7. 

Piorry's  percussion  tones,  37. 

Pitch  of  percussion  sounds,  31. 

Pleximcter,  the,  26. 

Potain  on  cardiac  reduplication, 
101. 

Position  of  patient  under  exam- 
ination, 4. 

Powell,  Douglas,  on  vocal  reson- 
ance, 77. 

Pre-systolic  murmur,  the,  107. 

Pterygoid  chest,  the,  10. 

Pulmonic  sounds,  area  of,  97. 

— —  murmur,  the,  116. 

Pulsation  of  abdominal  aorta,  131. 

Rales,  63. 

Rille,  the  sonorous  or  sibilant.  65. 

the  mucous  or  bubbling,  66. 

the  clicking,  67. 

the  crepitant,  67. 

the  mixed  or  indeterminate, 

69. 

the  muco-crepitant  or  sub- 

crepitant,  69. 

the  crackling,  70. 

the  gurgling,  70. 

the  metallic,  70. 

the  friction,  71. 

Reduplication  of  heart  sounds, 
101. 

Mechanism  of,  102,  103. 

Regions  of  the  chest,  4. 

abdomen,  124. 

Reporting,  outline  for,  150. 
Resistance,  percussiou,  44. 
Resonance,  percussion,  32. 

wooden,  34. 

absence  of,  40. 

diminished,  41. 

increased,  41. 

amphoric,  43. 

vocal,  73. 

Respiration,  movements  of,  13. 

rate  of,  14. 

degree  of,  15. 

irregularity  of,  16. 

abdominal,  17. 

thoracic,  17. 

rhythm  of,  18. 

saccadee,  57. 

soufflante,  61. 


156 


INDEX. 


Respiratory  murmur,  origin  of,  53. 

Dr.  Coats  on,  53. 

wavy,  jerky,  or  cog- 
wheel, 5(3. 

harsh,  59. 

bronchial,  60. 

tubular,  61. 

cavernous,  62. 

amphoric,  62. 

Rhonchus,  66. 

Rhythm  of  cardiac  sounds,  91. 

murmurs,  106. 

Rickety  chests,  the,  7. 

Roger  and  Barth  on  wavy  respir- 
ation, 57. 

Sonorous  and  sibilant  rsile,  the, 

65. 
Sounds,  amount  of  percussion,  30. 

quality ,  31. 

musical  v.  noise,  31. 

— —  voice,  73. 

Sf)leen,  examination  of,  142. 

enlargement  of,  143,  144. 

Stethoscope,  the,  46. 

precautions  in  using,  48. 

Stomach,  examination  of,  140. 

dilatation  of,  141. 

Symptoms  and  signs,  1. 
Systolic-vesicular   murmur,  the, 

57. 
Sub-crepitant  rclle,  the,  69. 
Succussion,  78. 
Superficial  cardiac  dulness,  90. 


Thrills,  cardiac,  88. 
Tinkling,  metallic,  70. 
Trachial  sound,  50. 
Tricuspid  sounds,  area  of,  97. 

murmur,  the,  116. 

Tubular  respiration,  61. 
Tumours,  abdominal,  130. 

ovarian,  148. 

Tympanitic  note,  the,  28,  32,  42. 

Umbilical  region,  125. 
Umbilicus  in  obesity,  126. 

in  peritoneal  dropsy,  126. 

Unilateral  deformities,  12. 

Venous  murmurs,  122. 

stasis  and  pulsation,  121. 

Vesicular  sound,  the,  51. 

diminished,  54. 

suppressed,  55. 

exaggerated,  55. 

Vocal  fremitus,  21. 

resonance,  73. 

increased,  74, 

diminished,  76. 

altered  quality  of,  77. 

Walshe  on  the  respiration  periods, 
14. 

crepitant  rale,  69. 

Wavy  respiration,  56. 
Woillez's  cyrtometer,  19. 
Wooden  note,  the,  34. 


PRINTED  AT  THE  UNIVERSITY  PRESS,   GLASGOW. 


COLUMBIA  UNIVERSITY  LIBRARIES 


0052114 


39 


DATE  DUE 


, 


Demco,  Inc.  38-2S3 


